Pediatric Cheerleading-Related Head Injuries and the “Double Down” Rule Change

BACKGROUND USA Cheer enacted the “double down” rule change ahead of the 2012–2013 season, prohibiting an advanced stunt among high school and lower grade-level cheerleading teams. In cheerleading, stunting describes performing a coordinated skill in which an athlete (the “flyer”) is lifted, supported, or thrown in the air by teammates (the “bases”). The “double down” rule change aimed to reduce concussions from teammate collisions during execution of a dismount skill, in which the flyer completes a 720-degree mid-air twist before being caught. This study hypothesized that the rule change may decrease emergent head injuries among pediatric cheerleaders. METHODS The National Electronic Injury Surveillance System was queried for cheerleading-related injuries in patients aged 6 to 18 years from 2004 to 2023 presenting to US emergency departments. Demographics, mechanisms of injury (MOI), and national estimates were analyzed. Injury trends per 100 000 cheerleaders were analyzed via interrupted time series. RESULTS A total of 15 799 (National Estimate 551 258, 95% CI 475 781-626 736) patients were included across 2004–2023. Fourteen percent had concussions/closed head injuries, frequently secondary to stunting (39%) and teammate collisions (37%). Prior to 2012, overall injuries, head injuries, and stunting/teammate collision as MOI were increasing (P < .05). After 2012, overall injuries, head injuries, and teammate collision as MOI decreased (P < .05). Stunting as MOI stabilized after 2012 (P = .12). Injuries cyclically peaked during return-to-sport/activity periods. CONCLUSIONS Pediatric head safety in cheerleading improved after implementation of the “double down” rule change. This study demonstrates safety benefit in regulating an advanced maneuver to skill level/environment and highlights an opportunity to reduce injury during return-to-sport/activity periods.