U.S. — A 2012 rule change banning the "double down" twisting dismount in cheerleading was followed by a decrease in concussion and head injury trends, according to a study published in Pediatrics. The National Federation of State High School Associations (NFHS) and USA Cheer implemented the ban for stunts performed in high school and lower-level grades.

Audrey Litvak, an orthopedic surgery resident, and her colleagues conducted the study by querying the National Electronic Injury Surveillance System (NEISS) database for cheerleading-related injuries between 2004 and 2023. The analysis included 15,799 patient records, representing an estimated 551,258 patients nationwide, with an average age of 13.8 years; 98% of the injured patients were girls. Overall, 14% of the identified cheerleading injuries were concussions or closed head injuries.

From 2004 to 2012, concussions and closed head injuries per 100,000 cheerleaders showed an upward trend. Stunting as an injury mechanism also trended upward during this period, as did teammate collisions. The trend for concussions and closed head injuries per 100,000 cheerleaders decreased after 2012. After the ban, stunting as a mechanism of injury stabilized, and teammate collision as a mechanism of injury decreased.

Litvak commented on the study's findings, stating, "In a decisive move ahead of the 2012-2013 season, the NFHS [National Federation of State High School Associations] and USA Cheer proactively prohibited the 'double down' maneuver -- a stunting skill involving a 720-degree twisting dismount performed by a flyer -- in high school and lower grade-level cheerleading." She added that the "ban aimed to explicitly address safety concerns regarding concussion risks linked to teammate collisions during the stunt; yet, despite its critical safety implications, no prior studies have analyzed the effects of the 'double down' rule change." Litvak noted that "furthermore, despite the popularity of cheerleading, studies analyzing rule changes and long-term injury trends remain limited," adding that "this is in part due to an absence of a dedicated injury surveillance system, which limits evidence-based safety guidelines and recommendations." She said, "I think the most surprising and certainly the most encouraging finding was how clear the decreasing trend in both pediatric head injuries and the associated mechanisms of injury were after the rule change." Litvak added that while the study cannot establish causation, the results suggest that "thoughtfully designed, evidence-based safety policies can make a meaningful difference."

Why It Matters

The study provides data on the impact of a 2012 safety regulation in cheerleading. Litvak stated, "Cheerleading involves unique mechanisms for head injury, particularly during stunting, where height, inversion skills, and teammate contact all contribute to concussion risk." This research contributes to understanding injury patterns in youth sports, an area where studies analyzing rule changes and long-term injury trends have remained limited.