Now that we’ve established cheerleading as a sport, why does it matter to sports medicine?
My point in painting this picture in Part 1 of cheerleading-as-a-sport is not because I want to see cheerleading in the Olympics. It has nothing to do with my former 6th grade dreams to become a cheerleader. There is the bigger issue. At the end of the day, as with all other sports, cheerleaders get injured. The more participants and complex skills that are required for participation, the more kids will get hurt.
Just as with any other athlete, we are all faced with having to understand cheerleading so that we can rehabilitate them back to their sport. Or better yet—prevent the injuries in the first place. Part of understanding a sport you’ve never done is taking the time to learn about it. So I’ve been to cheer practice, a competition, got the team t-shirt, and have been doing some bedtime reading. I’ve been completely out-tumbled by a 6 year old, too.
According to Shields & Smith (2009 and 2010), some of the most common injuries in cheerleaders (of any variety) are ankle injuries, knee injuries, and low back injuries. When humans have to lift other humans overhead, there is going to be a risk of falling. Either the lifter (known as the “base”) or liftee (known as the “flyer”) could be injured as a result of a flying human failure (that’s a technical term, by the way). Shields & Smith showed that up to 52% of all injuries in competitive cheerleading happen during stunts, up to 24% occur specifically to the base/spotter, 15% from tumbling and 14% from traumatic falls of the flyer. That’s a lot of flying human failure.
In addition to stunting and tumbling skills, the surface on which these athletes cheer may vary from grass to spring floor, resilite (foam) to hardwood floor. The same 2009 study mentioned above showed that 34% of competitive cheerleading injuries occurred on foam floor and 30% on spring floor. The diversity in competition/performance surface literally impacts an athlete’s ability to perform certain skills and has the potential to place undue strain on certain areas—putting them at greater risk for injury. A different study by the same researchers showed marked differences in risk for head injury in cheerleading stunts performed on various surfaces, with higher height of stunt and lower impact-absorbing surfaces leading to greater risk for injury.
Patients of mine have ranged from the competitive cheerleader with a traumatic ACL tear or ankle sprain, to the sideline cheerleader with a stress fracture in the back from improper base and tumbling mechanics. I’ve seen flyers who have fallen from a stunt with severe concussions. I wrote about concussion in cheerleading last month, and the CDC has some great educational information and athlete stories out to spread the word, too.
Last month I began working with a 15 year old high school cheerleader/tumbler who very eloquently told me the reason for her injury was “because I don’t tumble or base with the right form.” Not only was I impressed that a 15 year old identified the root of her problem, but she identified a risk factor that Shields & Smith (2009 and 2010) have shown to be the biggest predictor for injuries in bases. Remember how I mentioned in Part 1 how impressed I was with the University of Kentucky base body mechanics? I take notes for my patients. This is part of what we make sure our bases can do before they can return to cheerleading after injuries. Check out this photo of great base mechanics being taught in 4-6 year olds. Great coaching from an early age instills great injury prevention for the future.
So what do we do in PT? I find that generally for all cheerleaders, no matter what their position or role, the treatment plan mirrors the same plans that I use for gymnasts, divers, or even pole vaulters with similar injuries. The only difference is that for several sideline and all star cheerleaders, we also have to train the skill of avoiding flying human failures.
It is unfortunate to be injured, but fortunate when a young cheerleader ends up in physical therapy. I see it as a great educational, rehabilitative and prevention opportunity to keep a young athlete active and engaged in the sport he or she loves so that he or she can move into a healthy and active adulthood. I love a good challenge and love being creative with my PT skills to develop cheerleading-specific programs to help these young athletes get back to their sports.
I use some cool tools like Pilates apparatus and Redcord Neurac to design kid-friendly and cheer-specific exercises while educating on alignment, spinal mechanics, central stability, breathing mechanics, and all other “typical” concepts I teach to other tumbling and flying patients. If you want to read more about other “core” ideas I incorporate into my young tumbling and stunting athletes, visit this blog or check out this video from my PT colleague Julie Wiebe in Los Angeles.
Unfortunately, many young and even collegiate level cheerleaders do not often make it to a medical provider. In fact, the same 15 year old I mentioned above was injured then immobilized for 6 weeks. That’s a long time to not move a body part, folks. Had her mother not brought it up in conversation with me one day, she would have returned to cheerleading without correcting the imbalances and poor mechanics that likely led to the injury in the first place. As I mentioned, even she knew her mechanics were an issue. They had to ask to be referred to physical therapy. It shouldn’t happen that way.
The disconnect in sports medicine: why cheerleaders don’t get the right care
Why is it that cheerleaders do not regularly receive medical attention? Due to the fact that several sport governing bodies like the NCAA, AAU and sports medicine governing bodies like the ACSM and NATA do not always recognize cheerleading as a sport, cheerleading does not receive money nor sanctions to create a standard set of rules and standards of medical care. It is not heavily researched, though several small groups of researchers have begun to explore this concept. The American Academy of Pediatrics released a position statement on cheerleading. The STOP Sports Injuries campaign also has begun with cheerleading advocacy & safety campaigns.
Most cheerleading competitions are not held in traditional athletic venues; rather they may be held in large convention centers which may not be designed to support emergency medical needs. It is rare to hear of athletic trainers covering cheerleading events and competitions, or for a cheerleading squad to have their own team physician. Without recognition by national and/or international sports and sports medicine governing bodies, there is no requirement for standardization of safety and care.
Enter several of the national cheerleading safety organizations which have formed over the years. Some have been formed by parents who see the need for awareness and advocacy for their young athletes. It’s not perfect, but it’s definitely a start. See links to some major cheerleading safety organizations below:
American Association of Cheerleading Coaches and Administrators (AACCA)
National Cheer Safety Foundation (NCSF)
United States All Star Federation (USASF)
These organizations are not necessarily unified. Each has different rules and standards for competition and performance and they have different governing “roles” for each type of cheerleading. The spread of leadership and rules contributes to confusion of “who’s in charge” and requires a very diverse skill set in coaches and in athletes.
As we move along the chain from national organizations into the various forms of more “local” cheerleading, including high school, middle school and recreational leagues-there is even less organization. Some school systems include cheerleading as a varsity sport, while others call it a “club.” In college, some schools offer varsity scholarships for competitive cheerleading, while at others it is not recognized as a varsity sport. The NCAA Injury Surveillance survey, an ongoing project chronicling incidence and risk factors for injuries in 16 collegiate sports does not include cheerleading in its study of collegiate sports. This means that these athletes may not be covered nor managed by the school’s athletic training and medical team. They may not be required to undergo preseason physicals or baseline concussion testing, two key injury prevention checkreins. At the end of the day—there is no standardization of rules and care. This leads to an overall problem of funding for research, prevention programs, and management.
In summary, without all of this information, people just don’t know the right way to handle cheerleaders. It’s a safety issue.
What do we do about this?
So what do we do about this? We have to change our language and understanding. There is no use in denying it as a sport. What does one gain from doing this? Does it make one feel like more of an athlete to say that someone else isn’t an athlete? A 2004 study showed that the Vo2 max, body composition, strength & endurance of collegiate cheerleaders rivals that of other collegiate athletes. They’re in shape, they are performing feats that require a high level of athletic skill, and they deserve the same wellness and prevention attention of other athletes. With the number of cheer-related concussions and injuries on the rise, it’s just not worth the risk of ignoring it at this point.
The AACCA is one of several organizations offering a credentialing process for cheerleading coaches. While there are likely many non-credentialed skilled and talented coaches out there, it is generally accepted credentialing protects the consumer—in this case the athlete and family. It improves safety awareness, injury prevention/management, and standardization of coaching and level progression protocols. While there has been conflicting evidence to show the relationship between coaching credential and injuries, a 2004 study in North Carolina high school competitive cheerleaders showed a 40% decrease in cheerleading injuries when credentialed coaches were present. I am a firm believer that a credential does not guarantee skill. However, it does show a commitment to the betterment of a profession and a sport. Find a credentialed coach near you.
In the case of the young cheerleader, this is something that runs rampant on my caseload—and I blogged earlier this year about how am seeing injuries and early specialization in sports from increasingly younger ages. Some of that is parent-driven, as described in this post, but some of it is culture-driven. Early specialization leads to injuries. It’s a problem. But on the flip side-there has to be a balance. Our kids need to stay healthy and active, and sometimes early participation and specialization in a sport is a way to do that.
Ride the cheerleading safety and prevention wave with me! You just might get to wear a cool shirt like the one below and support one of the fastest-growing athletic activities for young athletes.
Out of respect for all sports, the comparisons made in this post were not meant to downplay or discount the hard work or dedication of athletes in any other sport or activity. In addition, this was not meant to be an exhaustive post about all factors which contribute to sports injuries in cheerleaders. Be on the lookout for future posts that highlight additional issues in these and other athletes. I welcome your feedback and thoughts for future ideas.