'A sport that gets overlooked': Cheerleaders risk concussion, broken bones, joint injuries

Last month, a north Texas high school cheerleader became paralyzed after falling while doing a stunt. 

It reminded many people that an injury like that at a high school football game isn't reserved for the football players.

"These are absolutely tremendous athletes in a sport that gets overlooked sometimes," says Dr. Kelly Cline, a pediatric orthopedic surgeon and sports medicine specialist with Texas Orthopedics. "When you see what their bodies are doing it's incredible."

She sees injuries in kids across all sports, and while football might bring in the most injuries, she sees cheerleaders coming in, too.

They are doing more and more stunts, pushing their bodies in ways that cheerleaders weren't a decade or two ago. The injury rates have reflected that, Cline says, and some studies put cheerleading just behind football for injuries. 

The injuries are happening from both overuse and accidents, and they can be anything from a sprain or broken finger to an ACL tear, broken limb, concussion or spinal injury. 

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What to know about concussions and cheerleading

About a third of cheerleading injuries are concussions, caused by hitting the ground or another cheerleader. Often it's the flyer, the person in the air, but sometimes it's the base, the person supporting the flyer, who can get hit in the head by the flyer. The tumblers, those cheerleaders who do gymnastic passes, also can run into each other or fall. 

You don't have to hit something with your head to have a concussion, says Dr. Katherine Labiner of Child Neurology Consultants of Austin. A head moving back and forth quickly can cause a concussion (think whiplash). 

Girls are more susceptible to concussions because their ligaments are looser and their necks are longer, she says. That makes it easier for their heads to snap back quickly.

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Spinal injuries from overuse

Spinal injuries are rare, but they can happen. "Paralysis is always a risk in this," Labiner says. 

What is more common is an overuse injury from hyperextending the back and not having good core strength to support the back. It can be like a whiplash but lower down. 

That repeated hyperextension also can damage bones.

Sometimes nerves can get pinched or are swollen, causing tingling in arms, hands, legs or feet. 

Broken, sprained, strained

Landing the wrong way or someone landing on you can cause broken bones, or ankle or wrist sprains. Overuse also can lead to these injuries. 

Up until about age 14, kids still have growth plates that are open and often they will break bones at those plates. Later on, when those growth plates are closed, they might pull a tendon or tear a ligament instead. 

Girls are at a higher risk for knee injuries than boys because they are naturally knock-kneed and have weaker knee and hip joints. This can cause their knees to buckle inward when they land, damaging the structures around the knee. 

Kids also don't have good balance until late in elementary school or even sometimes middle school.

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How to avoid injuries in cheerleading

Like any sport, strength and conditioning is key, along with time off to lessen overuse injuries.

Dr. Catherine Sargent of Central Texas Pediatric Orthopedics recommends that 30% of practice should be focused on warming up, stretching, and strengthening the core muscles and the muscles around the hips, shoulders, arms and legs. These muscles are needed to support the choreography and stunts the cheerleaders will do. 

They also need to allow enough time to cool down and stretch to avoid pulled hamstrings and groin muscles. 

"Life is very busy for kids," Sargent says. "You have to get in the car so we can get home so we can have dinner so you can do homework so you can get to bed. Kids have to have a chance to cool down, to hydrate to prevent injury."

Kids also need to take time off, which in the world of competitive cheerleading is hard because it's a year-round sport. Some cheerleaders also are doing competitive cheer and school cheer at the same time. 

The recommendation with all sports is that even non-injured kids take at least two months off a year, and when they do return, they ease into the sport gradually, Sargent says. 

She also recommends the number of hours a week kids spend doing one sport be not any more than their age minus 3, so a 7-year-old should be doing cheer only four hours a week. A 14-year-old would have an 11 hour limit. They also need to have at least one day off a week. 

Injury also happens when kids do not have the proper nutrition to support the activity they are doing. In cheerleaders, especially, Sargent sees athletes with eating disorders. If they don't get enough calories, they don't have proper bone strength, which can lead to fractures. They also could become light-headed or not have enough energy to do a stunt properly. 

A big tipoff for not getting enough nutrition is if they had started menstruating and they stop. 

Fatigue also plays a factor in injuries. 

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Returning to play

Just like football players, cheerleaders should get a baseline concussion screening before they start practicing and competing. This helps their physician know what is normal for them mentally and gauge what neurological damage they still might have after a concussion, even if the more obvious signs like headache have gone away. 

Once a child gets one concussion, they are 30 percent more likely to get a second concussion, but that's because they go back to doing the thing that caused the first concussion, Labiner says. It's not about the number of concussions you've had, either. The question becomes: Did you fully heal from each concussion before returning to that activity? 

"I remind them you only get one brain," Labiner says. "It's the one thing in your body I cannot replace for you." 

Just like with football players, there's a return to play protocol that cheerleaders should go through. It starts off small with whether they can walk for 20 minutes without any concussion symptoms, such as sensitivity to light or noises, headache, dizziness or brain fog. The next step is riding a stationary bike, then working up to practice with no contact, to eventually back to practice with contact and a competition or game. 

"Some kids may heal within a week or two and keep progressing," Labiner says. "Other kids may stall out on one step and stay at that one step. They can be at any step indefinitely." 

She is counting on kids to be honest about what they are feeling and not feel pressured to return when they are not ready, especially with a brain injury. 

Before she will medically clear someone after a concussion, Labiner says, they have to be mentally and emotionally ready to return. If they are scared or worried that they are going to reinjure themselves, they risk that or injuring a teammate.

Each injury is different with how long it will take to heal. Sargent estimates that something like a muscle strain or a ankle sprain might take two to three weeks. A fracture could be six weeks, an ACL tear three to four months, back strains could be three months.

"The biggest concern is reinjury," Sargent says. "With an ACL, I not only need to get them over the injury and surgery, I need to train them and condition them so it doesn't happen again." 

Cheerleaders also need to avoid participating injured, Sargent says, because if they overcompensate using another muscle group, they can strain that muscle group. They could risk getting another cheerleader hurt if they don't balance like they normally would or don't have their usual strength to hold up or catch another cheerleader. 

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Return when you are ready, not before

Sargent, Cline and Labiner all see the pressure on cheerleaders to return to the sport as quickly as possible. They can feel like they are letting the team down. 

"People don't realize in competitive cheering there is as much pressure in teams as there is in football," Labiner says. "They have a reputation and nobody wants to be the person to ruin the reputation." 

Cline says she can't think about the team. "I have to think about this athlete. This is their skeleton, their bones. ... If we return them too early, they could get more injured."

Sargent realizes that for many cheerleaders, this activity is also tied to their social life. Being sidelined can have a negative impact on their mental health. There are ways they can still support the team while not practicing or taking the field. 

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Once they do return, they should not expect to be able to continue where they left off. Their bodies might be different than the last time they cheered because they grew or gained weight or don't have the same muscle memory for a skill.

None of these doctors would recommend against cheering, but it should be done with good spotters, good training and breaks. 

Cheerleading, Labiner says, allows people to be both athletic and artistic, and art is very good for kids emotionally. 

"It also teaches people how to be a teammate and to physically learn to support other people," she says.