Cheerleading and Lower Extremity Injury

Cheerleading is often overlooked as an injurious sport and scant studies have focused on the mechanisms and incidences of injuries. 
But the reality is that cheerleading has evolved over the past century-and-a-half  from a pep-group chanting in the bleachers to a competitive combination of high-impact dance and extreme-skill performance sport: filled with high-flying stunts and dangerous skills.  Cheerleading has quickly become one of the most necessarily accurate professional sports due to the advancement of trick stunts and the subsequent improvements in training practices. In order to pull off those high-flying moves, athletes must train daily at intensities formerly reserved for the team sports they cheer for. Thus, they are subject to common over-training injuries which include ligamentous sprains, muscular strains, fractures, and contusions. 
Dr. Jay Greenstein, CEO of Sport and Spine Companies in the Washington, DC area and a leader in the chiropractic industry at the national level offers his insight:
“Cheerleaders suffer lots of lower extremity injuries. A 2012 study published in the Journal of Trauma and Acute Care Surgery revealed that lower extremities injuries made up approximately 30% of all cheerleading injuries seen in the emergency room over a 5 year period. A study published in the American Journal of Emergency Medicine reported that an even higher rate of lower extremity sprains and strains at 42% of total injuries occurring. 
Athletes should be aware that muscle compensations due to injuries of this nature create postural imbalances that can go unnoticed resulting in alignment issues that have a deeper affect on a person's performance and safety.  An early evaluation for orthotic need can assist in reducing the risk of posterior tibial tendon, achilles tendon, and peroneal (fibularis) sprains and strains. In 2011, Franklyn-Miller, A,et.al. found the use of customized foot orthoses during training for those assessed as being at-risk resulted in a 20% reduction in lower limb overuse injury rate.   Stabilizing the body through guided and controlled rehabilitation, skeletal manipulation, and orthotic use can keep the body aligned, improve sensorimotor control, and maintain better balance. Dr. Greenstein continues:"While functional elements of muscle imbalances, prior injury, and thus poor sensorimotor function are key variables of this epidemic, we also realize that there are anatomic variables that must be addressed. In a study published in the Clinical Journal of Sports Medicine, the application of a  custom foot orthoses “have an immediate effect on (lower extremity) dynamics.” So, in thinking about prevention first, having a pre-emptive evaluation to determine the need for a custom orthoses to improve lower extremity dynamics and function, and reduce the risk of injury, is a worthwhile endeavor.”
A cheerleading-specific lower extremity evaluation will include objective measures of range of motion, strength, spinal alignment, pelvic obliquity, leg length discrepancy, knee alignment, hindfoot alignment, plantar fascia patentcy, sub-talar joint axis, navicular drop, flexor hallucis congruency, heel-ball ratio, and forefoot to hindfoot alignment during static and weightbearing sport maneuvers.  In fact, these elements are necessary to fabricate the most appropriate device for any person seeking to improve their performance through balance and injury prevention.

Notes on Cheerleading injury incidence and prevention
In 2002, the Journal of Pediatrics published an epidemiological review of cheerleading injuries in children from 1990-2002.  The authors found the body parts injured were lower extremity (37.2%), upper extremity (26.4%), head/neck (18.8%), trunk (16.8%), and other (0.8%). Injury diagnoses were strains/sprains (52.4%), soft tissue injuries (18.4%), fractures/dislocations (16.4%), lacerations/avulsions (3.8%), concussions/closed head injuries (3.5%), and other (5.5%). Children in the 12- to 18-year age group were more likely to sustain strains or sprains to the lower extremity than 5- to 11-year-olds (P < .01; RR: 1.62; 95% CI: 1.50–1.88). Since this land-mark paper was published, catastrophic injuries in cheerleading has continued to rise.  The latest information (Oct 2012) shows the number of catastrophic injuries related to cheerleading has increased from 1.5 annually from 1982 to 1992 to 4.8 per year from 2003 to 2009 according to the American Academy of Pediatrics. Catastrophic injuries include closed-head injury, skull fractures and cervical spine injuries resulting in permanent brain injury, paralysis or death.
 New recommendations in the guidelines of injury prevention in cheerleading have just been released and include:

• National designation of cheerleading as a sport for better quality control.
• Mandated preseason physicals and access to qualified strength and conditioning coaches.
• Mandatory spotting technique training for all participants.
• Not allowing participants to perform stunts until they have demonstrated appropriate skill progression.
• Pyramid and partner stunts should be performed only on a spring/foam floor or grass/turf; pyramids should not be more than two people high.
• All participating coaches and parents should have access to a written emergency plan.
• Cheerleaders with head injuries should not be allowed to participate in the sport until given clearance from a health professional.

Cheerleaders perform as "Bases", Flyers", or "Spotters" depending on the stunt being performed and the athlete's individual body-type and skill set.  Whether walking across four peoples' backs suspended in mid air in a "walking tabletop" or flying high during a "basket toss", today's cheerleaders must be in the best shape possible and take every precaution available to ensure their safety. Graceyfeet insoles and Graceyfeet Invisi-Tech head gear and body armor reduce impact shock up to 60% and are effective methods for lowering the incidence of pressure-related injury in impact sports.   


Thank you to Dr. Jay Greenstein for his contribution to this article.
http://www.ssrehab.com/

Council On Sports Medicine and Fitness. Pediatrics. 2012;doi:10.1542/peds.2012-2480.

J Physiother. 2011;57(3):193.
Foot orthoses can reduce lower limb overuse injury rate.Landorf KB.
SourceLa Trobe University, Australia.

PEDIATRICS Vol. 117 No. 1 January 1, 2006
  pp. 122 -129
  (doi: 10.1542/peds.2005-1139)

American Academy of PediatricsPolicy Statement: Cheerleading Injuries: Epidemiology and Recommendations for Prevention

• COUNCIL ON SPORTS MEDICINE AND FITNESS

Pediatrics peds.2012-2480; published ahead of print October 22, 2012,doi:10.1542/peds.2012-2480

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