Introduction

        In 1931 the American Football Coaches Association initiated the First Annual Survey of Football Fatalities and this research has been conducted at the University of North Carolina at Chapel Hill since 1965.  In 1977 the National Collegiate Athletic Association initiated a National Survey of Catastrophic Football Injuries which is also conducted at the University of North Carolina.  As a result of these research projects important contributions to the sport of football have been made.  Most notable have been the 1976 rule changes, the football helmet standard, improved medical care for the participants and better coaching techniques.

        Due to the success of these two football projects the research was expanded to all sports for both men and women, and a National Center for Catastrophic Sports Injury Research was established.  The decision to expand the research was based on the following factors:

 1.  Research based on reliable data is essential if progress is to be made in sports safety.
 2.  The paucity of information on injuries in all sports.
 3.  The rapid expansion and lack of injury information in women's sports.

 1.  Fatality
 2.  Non-Fatal - permanent severe functional disability.
 3.  Serious - no permanent functional disability but severe injury.  An example would be a
      fractured cervical vertebra with no paralysis.

 Direct   - Those injuries which resulted directly from participation in the skills of the
      sport.
  Indirect - Those injuries which were caused by systemic failure as a result of exertion
      while participating in a sport activity or by a complication which was secondary
       to a non-fatal injury.

        Data were compiled with the assistance of coaches, athletic directors, executive officers of state and national athletic organizations, a national newspaper clipping service and professional associates of the researchers.  Data collection would not have been possible without the support of the National Collegiate Athletic Association, the National Federation of State High School Associations and the American Football Coaches Association.  Upon receiving information concerning a possible catastrophic sports injury, contact by telephone, personal letter and questionnaire was made with the injured player's coach or athletic director.  Data collected included background information on the athlete (age, height, weight, experience, previous injury, etc.), accident information, immediate and post-accident medical care, type injury and equipment involved.  Autopsy reports are used when available.

        In 1987, a joint endeavor was initiated with the Section on Sports Medicine of the American Association of Neurological Surgeons.  The purpose of this collaboration was to enhance the collection of medical data.  Dr. Robert C. Cantu, Chairman, Department of Surgery and Chief, Neurosurgery Service, Emerson Hospital, in Concord, MA, has been responsible for evaluating the medical data.  Dr. Cantu is also the Past-President of the American College of Sports Medicine.

Summary

        Fall Sports (Tables I - VIII)

           Football

        As indicated in Tables I through VIII, football is associated with the greatest number of catastrophic injuries.  For the 2005 football season there was a total of 10 high school direct catastrophic injuries, which is the lowest number since the research was started in 1982.  College football was associated with one direct catastrophic injury in 2005, which is also the lowest number since the Center was started in 1982.

        In 1990, as shown in the Annual Survey of Football Injury Research 1931-2006,  there were no fatalities directly related to football.  The 1990 football report is historic in that it is the first year, and the only year,  since the beginning of the research in 1931, that there has not been a direct fatality in football at any level of play.  This clearly illustrates that this type of data collection and constant analysis of the data is important and plays a major role in injury prevention.  The 1994 data shows zero fatalities at the high school level and one at the college level, with a slight rise in 1995 to four.  These numbers are very low when one considers that there were 36 football direct fatalities in 1968.

        In addition to the direct fatalities in 2005 there were also ten indirect fatalities.  Eight of the indirect fatalities were at the high school level and two were at the college level.  The causes of the high school indirect deaths were one heat stroke, one hit by lightning, three heart related, and three unknown.   The college indirect deaths were one heat stroke and on viral meningitis

        In addition to the fatalities there were six permanent disability injuries in 2005.  Three were cervical spine injuries and three were brain injuries.  This number is a decrease of six when compared to 2004 data.  Five of the injuries were at the high school level and one at the college level.  

        Serious football injuries with no permanent disability accounted for three injuries in 2005 - all three at the high school level.  High school athletes were associated with one cervical spine fracture and two brain injuries with full recovery.

        This decrease in catastrophic football injuries illustrates the importance of data collection and being sure that the information is passed on to those responsible for conducting football programs.  A return to the injury levels of the 1960's and 1970's would be detrimental to the game and the participants.

          Cross country

        Cross country was not associated with any direct or indirect injuries in 2005.  For the 24 years indicated in Tables I through VIII, cross country was associated with one direct non-fatal injury and 22 indirect fatalities at the high school level and one indirect fatality at the college level.  Twenty-one of the indirect fatalities were heart related, one was caused  by a seizure, and the cause of one was unknown.  Autopsy reports revealed congenital heart disease in four of these cases.

          Soccer

        Table I shows that high school soccer shows one direct catastrophic injury in 2005 and a total of 16 direct catastrophic injuries for the past 24 seasons.  The three direct catastrophic injuries in 1992 was the highest number in the past 24 years. There were also two  high school soccer indirect fatalities in 2005.  In 2005 college soccer was not associated with any direct or indirect catastrophic injuries.   In addition to the high school and college injuries in 2005, there was one youth soccer death in 2005 and the death of a 15 year-old boy who received a head injury when eh and his friends were trying to mvoe a 300 pound soccer goal.  The goal fell over onto the injured boy's head.  

    Concussion injuries related to heading is a controversial area in soccer.  There are helmet manufacturers that are now making soccer helmets to protect the participants from brain injuries while heading, even though the research indicates that concussion injuries during heading are related to head-to-head contact and not ball contact. In a special edition of the Journal of Athletic Training, July-September 2001, an article by Donald Kirkendall and William Garrett, Jr, the authors stated that it is difficult to blame purposeful heading for the reported cognitive deficits when actual heading exposure and details of the nature of head-ball impact are unknown.  They go on to sat that concussions are a common head injury in soccer (mostly from head-head or head-ground impact) and a factor in cognitive deficits and are probably the mechanism of the reported dysfunction.  In October 2001 the Institute of Medicine at the National Academy of Sciences held a one-day conference.  Experts on head injuries discussed the potential risk of heading, but reached no firm conclusions.  The American Academy of Pediatrics issued the following recommendation in March 2000: "The potential for permanent cognitive impairment from heading the ball needs to be explored further. Currently, there seems to be insufficient published data to support a recommendation that young soccer players completely refrain from heading the ball.  However, adults who supervise participants in youth soccer should minimize the use of the technique of heading the ball, until the potential for permanent cognitive impairment is further delineated.  In July of  2003 the National Federation of State High School Associations approved a rule that will allow soccer players to wear a headguard.  Prior to this rule only goalkeepers could wear such a device.  The National Center will keep abreast of this controversial area. 

        In 2003 there was another case of a child being struck by the goal post and dying.  A six year old male was struck in the head by a goal post that fell over and struck him in the head.  This type of accident should never happen.  The Consumer Product Safety Commission has stated that there have been at least 28 deaths from falling soccer goal posts and hundreds of injuries since 1978.  Most occurred with moveable goal posts and resulted from errors in moving the structures or anchoring them.  As mentioned above there was another soccer death in 2005.

         Field Hockey

        In 1988 field hockey was associated with its first catastrophic injury since the study began in 1982.  It was listed as a serious injury at the college level.  The athlete was struck by the ball after a free hit.  She received a fractured skull, had surgery and has recovered from the injury.  The 1996 data shows two field hockey direct injuries at the high school level.  Both injuries involved being hit by the ball and resulted in a head and an eye injury.  The 1999 data show on non-fatal injury at the high school level and one serious injury at the college level.  The high school injury involved the loss of an eye after being hit with the sick during a drill, and the college injury resulted in a fractured skull after being hit by a ball.  There were no direct catastrophic injuries in high school field hockey during the 2005 season.  There have been no indirect catastrophic injuries in field hockey since the beginning of the study in 1982, but there was one direct non-fatal injury a the college level.  The athlete had an avulsion of the distal half of the 5th phalanx of her right hand.  Finger was caught between the ball and the stick on a shot.  There have been no indirect catastrophic injuries in field hockey since the beginning of the study in 1982.

         Water Polo

        In 1992-93 high school water polo was associated with its first indirect fatality and in 1988-89 college water polo had its first indirect fatality.  There have been a total of four high school indirect fatalities in water polo and one at the college level.  There were no water polo fatalities in 2005.

Fall Summary

        In summary, high school fall sports in 2005 were associated with 11 direct catastrophic injuries. Ten were associated with football, and one with soccer.  Football had two fatalities, five involved permanent disability, and three were considered serious.  Soccer was associated with one death.  For the 24-year period 1982-2005, high school fall sports had 602 direct catastrophic injuries and 582, or 96.7%, were related to football participants.  In 2005 high school fall sports were also associated with eight football indirect fatalities and two in soccer  for a total of  ten indirect  fatalities.  For the period from 1982-2005 there was a total of 217 indirect fall high school catastrophic injuries.  Two hundred and sixteen of the indirect injuries were fatalities and 159 were related to football.  Fourteen of the indirect fatalities involved females – six soccer players, one water polo player, and seven cross-country athletes.  Females were also associated with four direct catastrophic injuries – three in field hockey and one in soccer.

        During the 2005 college fall sports season there were two total of one direct catastrophic injuries one in football and one in field hockey.  For the 24 years, 1982-2005, there was a total of 133 college direct fall sport catastrophic injuries, and 127 were associated with football.  Three were associated with soccer and three with field hockey.  There was two indirect college fatalities during the fall of 2005, and they were associated with football.  From 1982 through the 2005 fall season there were a total of 47 college fall sport indirect catastrophic injuries, and 46 of them were fatalities.  Thirty-nine of the fatalities were associated with football.  

        High school football accounted for the greatest number of direct catastrophic injuries for the fall sports, but high school football was also associated with the greatest number of participants.  There are approximately 1,500,000 high school and junior high school football players participating each year.  As illustrated in Table II, the 24 year rate of direct injuries per 100,000 high school and middle school football participants was 0.31 fatalities, 0.76 non-fatal injuries and 0.76 serious injuries.  These catastrophic injury rates for football are higher than those for both cross country and soccer, but all three classifications of catastrophic football injuries have an injury rate of less than one per 100,000 participants.  Table IV shows that the indirect fatality rates for high school football, soccer and cross country are similar and are also less than one per 100,000 participants.  Water polo rates are higher, but are based on only fourteen years of data, and water polo has approximately 23,000 male and female participants each year.

        College football has approximately 75,000 participants each year and the direct injury rate per 100,000 participants is higher than the other fall sports.  The rate, for the 24 year period indicated in Table VI, for college football fatalities is less than one per 100,000 participants, but the rate increases to 1.85 per 100,000 for non-fatal injuries and 4.78 per 100,000 participants for serious injuries.

        Indirect fatality rates are similar in college cross country and soccer, increase in football, with water polo being associated with the highest indirect fatality rate.  Based on 18 years of data, water polo has approximately 1,700 participants each year (Table VIII).  

        There were four college female athletes receiving a direct catastrophic injury in a fall sport for this 24-year period of time. There was one non-fatal injury and two serious injuries in field hockey, and one in soccer.  There were also three indirect deaths to a female in soccer.

        Incidence rates are based on 24 year participation figures received from the National Federation of State High School Associations and the National Collegiate Athletic Association.  (Figure I)

Winter Sports (Tables IX - XVI)

        College winter sports, Tables XIII - XVI, were associated with one direct catastrophic injury during the 2005-2006 school year.  The one injury was a non-fatal injury in basketball. During this same time period there were two indirect fatalities.  Both fatalities were associated with basketball.            

        A summary of high school winter sports, 1982-2006, show a total of 118 direct catastrophic injuries (8 fatalities, 63 non-fatal, and 47 serious) and 146 indirect.  Wrestling was associated with 55 or 46.6 percent of the direct injuries.  Gymnastics was associated with 13, or 11.04%, of the direct injuries.  Basketball was associated with 17 (14.4%), ice hockey was associated with 19 (16.1%), swimming was associated with 13 (11.0%) direct injuries, and volleyball one (0.85%).  Basketball accounted for the greatest number of indirect fatalities with 109, or 77.9%, of the winter total.

        College winter sports from 1982-2006 were associated with a total of 30 direct catastrophic injuries.  Gymnastics was associated with six (20.0%), ice hockey 12 (40.0%), basketball nine (30.0%), swimming one (3.34%), skiing one (3.34%) and wrestling one (3.34%).  There were also 40 indirect injuries (38 fatalities) during this time period.  Twenty-seven, or 67.5%, were associated with basketball, three in wrestling, two in ice hockey, five in swimming, one in skiing, one in gymnastics, and one in volleyball.

        High school wrestling accounted for the greatest number of winter sport direct injuries, but the injury rate per 100,000 participants was less than one for all three categories.  High school wrestling has approximately 238,000 male and 1,500 participants each year.  High school basketball and swimming were also associated with low direct injury rates.  As shown in Table X, ice hockey and gymnastics were associated with the highest injury rates for the winter sports.  Gymnastics has averaged approximately 3,907 males and 25,349 female participants during the past twenty-four years.  Ice hockey averages 27,000 male and 2,350 female participants each year.  A high percentage of the ice hockey injuries involve a player being hit by an opposing player, usually from behind, and striking the skate rink boards with the top of his/her head.

        Indirect high school catastrophic injury rates, as indicated in Table XII, are all below one per 100,000 participants.

        Catastrophic direct injury rates for college winter sports are higher when compared to high school figures.  Gymnastics had five non-fatal and one serious injury for the past twenty-four years, but the injury rate is 20.52 per 100,000 participants for non-fatal male injuries, and 5.58 per 100,000 for female non-fatal injuries.  Participation figures show approximately 609 male and 1,494 female gymnastic participants each year.

        College ice hockey was associated with eight serious and four non-fatal injuries in twenty-four years, but the injury rate is 4.36 per 100,000 male participants for non-fatal and 7.64 for male serious injuries.  There are approximately 3,800 male ice hockey participants each year.  The first female college ice hockey player received a direct serious injury during the 1999-2000 season.  The serious injury rate for female serious injuries was 7.36 injuries per 100,000 participants, and females averaged approximately 566 participants per year for the past 24 years.    Swimming non-fatal incidence rates were not as high as gymnastics or ice hockey, but could be totally eliminated if swimmers would not use the racing dive into the shallow end of pools during practice or meets.  In fact there has not been a direct injury in college swimming since the one non-fatal injury in 1982-1983.

        College wrestling had only one direct catastrophic injury from the fall of 1982 to the spring of 2006.  For this period of time there were 162,816 participants in college wrestling for an average of approximately 6,800 per year.  The injury rate for this twenty-four year period of time was 0.61 per 100,000 participants.  College skiing has approximately 600 female participants each year and the one fatality in 1989-1990 produced a fifteen-year injury rate of 7.16 per 100,000 participants. This was the only skiing direct fatality since the study was initiated. 

        Injury rates for male college indirect fatalities were high when compared to the high school rates.  Basketball had an injury rate of 6.75 fatalities per 100,000 male participants, skiing 6.32, ice hockey 1.09, and swimming 2.68. The year 1997-98 was the first year there were any indirect fatalities in wrestling. There were three deaths due to heat stroke associated with wrestlers trying to make weight for a match. The indirect injury rate for wrestling was 1.84 per 100,000 participants.

    The female indirect injury rate for basketball was 1.01 per 100,000 participants, 0.65 per 100,000 for volleyball, and 2.79 for gymnastics.

Spring Sports (Tables XVII - XXIV)  

        High school spring sports were associated with one direct catastrophic injury in 2006.  The one injury was a serious injury in track.  High school spring sports were not associated with any indirect injuries in 2006.  

        College spring sports were associated with one direct, non-fatal catastrophic lacross injury in 2006.  There was also one indirect fatality in lacrosse.

        From 1983 through 2006, high school spring sports were associated with 113 direct catastrophic injuries (Table XVII).  Thirty-two were listed as fatalities, 38 as catastrophic non-fatal and 43 as serious.  Baseball accounted for 44, track 58, lacrosse eight, and softball three.  Injury rates were less than one per 100,000 participants for each sport in all categories.  There were six direct injuries to females in track, three in softball, and one in lacrosse.    There were also 51 indirect fatalities in high school spring sports during this time span  (Table XIX).  Thirty were related to track, 14 in baseball, four in lacrosse and three in tennis.  Five of the indirect fatalities involved female track athletes.

        As illustrated in Table XXI, college spring sports were associated with 34 direct catastrophic injuries from 1983 to 2006.  Eleven of these injuries resulted in fatalities, 13 were listed as non-fatal and ten were listed as serious.  Baseball accounted for twelve injuries, lacrosse eleven, track ten, and equestrian one.  College females were associated with two non-fatal injuries in lacrosse, one in track, and one fatality in equiestrian.    Table XXIII shows that there were also ten indirect fatalities in college spring sports during this time.  Two indirect fatalities were associated with tennis, one was associated with track, two in baseball, three in rowing, and two in lacrosse.  There was one female fatality in tennis.

        Injury rates for high school spring sports direct injuries were low as illustrated in Table XVIII.  Baseball participation reveals approximately 415,000 male players and 875 female players each year, track 501,800 males and 405,000 females, and tennis 139,00 males and 143,000 females.  The baseball figures do not include the 308,000 softball participants each year.  Lacrosse has approximately 29,000 male and 19,000 female participants each year.  Injury rates, as shown in Table XX, for high school indirect injuries are also low.

        College spring sports, Table XXII, are related to low injury rates for direct injuries.  Men's lacrosse had four fatalities, three non-fatal and two serious injuries and the injury rates were higher than the other college spring sports. Female lacrosse players were associated with two non-fatal injuries and female track (pole vault) was associated with one non-fatal injury.  Equestrian was associated with a female fatality.   Participation figures reveal approximately 5,585 men and 3,800 women lacrosse players each year.  The 1991 and 2003 injuries were to  female lacrosse players.

        Rates for indirect college fatalities in baseball, tennis, and track are low with lacrosse being slightly higher.  There were two indirect tennis fatalities, one male and one female, but participation figures are low.  Men average approximately 7,700 and women 7,750 participants each year.  Rowing had the highest indirect injury rate at 32.38 injuries per 100,000 male participants and 0.00 for female participants.  There are approximately 1,800 male rowers and  6,600 female rowers each year.   (Table XXIV)

Discussion

        Football is associated with the greatest number of catastrophic injuries for all sports, but the incidence of injury per 100,000 participants is higher in both gymnastics and ice hockey.  There have been dramatic reductions in the number of football fatalities and non-fatal catastrophic injuries since 1976 and the 1990 data illustrated an historic decrease in football fatalities to zero.  This is a great accomplishment when compared to the 36 fatalities in 1968.  This dramatic reduction can be directly related to data collected by the American Football Coaches Association Committee on Football Injuries (1931-2006) and the recommendations that were based on that data.  Non-fatal football injuries, permanent disability, decreased to one for college football in 1995, 1999, 2004, and 2005.  There was a dramatic reduction in high school football from 13 in 1990 and 1993 to six in 2002 and five in 2005. There was an increase to eleven in 1995 and 1996, and 14 in 1997. The 2005 data show 5 non-fatal injuries and two fatalities in high school football.    Permanent disability injuries in football have seen dramatic reductions when compared to the data from the late 1960's and early 1970's, but a continued effort must be made to eliminate these injuries.  In addition, there were three serious injuries in football in 2005 - all three at the high school level.  All of the serious cases involved head or neck injuries and in a number of these cases excellent medical care saved the athlete from permanent disability or death.

        Football catastrophic injuries may never be totally eliminated, but progress has been made.  Emphasis should again be focused on the preventive measures that received credit for the initial reduction of injuries.
 

1. The 1976 rule change which prohibited initial contact with the head in blocking and  tackling.  There must be continued emphasis in this area by coaches and officials.
2. The NOCSAE football helmet standard that went into effect at the college level in 1978 and at the high school level in 1980. There should be continued research in helmet safety.
3. Improved medical care of the injured athlete.  An emphasis on placing certified athletic trainers in all high schools and colleges. There should be a written emergency plan for catastrophic injuries both at the high school and college levels.
4. Improved coaching technique when teaching the fundamental skills of blocking and tackling.  Keeping the head out of football!

    It should be noted that since 1978, according to the Consumer Product Safety Commission, there have been at least 28 deaths and hundreds of serious injuries from when movable soccer goals.  The most recent cases involved four boys attempting to move a soccer goal when it tipped over and hit a fifteen year-old boy in the head, causing his death.  There has been one fatality in this study, which involved a college athlete hanging on a soccer goal and the goal falling and striking the victim's head.

        On May 4, 1999, the Consumer Product Safety Commission and the soccer goal industry announced the development of a new safety standard that will reduce the risk of soccer goal tip-over. The ‘Provisional Safety Standard and Performance Specification for Soccer Goals” (ASTM-PS-75-99) requires that movable soccer goals, except very lightweight goals, not tip over when the goal is weighted in a downward or horizontal direction.  The standard also specifies warning labels must be attached to the goal, such as: “Warning: Always anchor goal.  Unsecured goal can fall over causing serious injury or death.”  For a free copy of :  “Guidelines for Movable Soccer Goal Safety,” send a postcard to CPSC, Washington, DC 20207.  Also available online:  http:cpsc.gov

   A Loss Control Bulletin from K & K Insurance Group, Inc., Fort Wayne, IN, suggests the following safeguards:

1. Keep soccer goals supervised and anchored.
2. Never permit hanging or climbing on a soccer goal.
3. Always stand to the rear or side of the goal when moving it - NEVER to the front.
4. Stabilize the goal as best suits the playing surface, but in a manner that does not create other hazards to players.
5. Develop and follow a plan for periodic inspection and maintenance (e.g., dry rot, joints, hooks).
6. Advise all field maintenance persons to re-anchor the goal if moved for mowing the grass or other purposes.
7. Remove goals from fields no longer in use for the soccer program as the season progresses.
8. Secure goals well from unauthorized access when stored.
9. Educate and remind all players and adult supervisors about the past tragedies of soccer goal fatalities.

  The Coalition to Promote Soccer Goal Safety
  C/O Soccer Industry Council of America
  200 Castlewood Drive
  North Palm Beach, FL 33408

        Men’s and women’s gymnastics and ice hockey were associated with higher injury rates at both the high school and college levels.  Gymnastics needs additional study at both levels of competition. Both levels have seen a dramatic participation reduction and this trend may continue with the major emphasis being in private clubs.  Lacrosse also had a higher injury rate at the college level.

        Ice hockey injuries are low in numbers but the injury rate per 100,000 participants is high when compared to other sports.  Ice hockey catastrophic injuries usually occur when an athlete is struck from behind by an opponent, slides across the ice in a prone position, and makes contact with the crown of his/her head and the boards surrounding the rink.  The results are usually fractured cervical vertebrae with paralysis.  Research in Canada has revealed high catastrophic injury rates with similar results.  After an in-depth study of ice hockey catastrophic injuries in Canada, Dr. Charles Tator has made the following recommendations concerning prevention:

 1.  Enforce current rules and consider new rules against pushing or checking from behind.
 2.  Improve strength of neck muscles.
 3.  Educate players concerning risk of neck injuries.
 4.  Continued epidemiological research.

        High school spring sports have been associated with low incidence rates during the past twenty-four years, but baseball was associated with 44 direct catastrophic injuries and track 58.  A majority of the baseball injuries have been caused by the head first slide or by being struck with a thrown or batted ball. If the headfirst slide is going to be used, proper instruction should be involved.  Proper protection for batting practice should be provided for the batting practice pitcher and he/she should always wear a helmet.  This should also be true for the batting practice coach. During the 2005 baseball season four high school pitchers were stuck in the head with batted balls.  One pitcher recovered, two were non-fatal at the time of this writing, and one died.  Two injuries took place in a game, one in batting practice, and one in a batting cage.  A new rule in fast pitch soft ball will require players to wear batting helmets equipped with NOCSAE approved facemasks/guards.  The rule will go into effect January 1, 2006.  

        The pole vault was associated with a majority of the fatal track injuries.  There have been 18 high school fatal pole-vaulting injuries from 1983 to 2006.  This does not include the coach who was demonstrating in 1998, bounced out of the pit, struck his head on concrete, and died. In addition to the fatalities there were also eleven permanent disability (8 high school and 3 college) and seven serious injuries (5 high school, one college, and one middle school).  All 36 of these accidents involved the vaulter bouncing out of or landing out of the pit area. The three pole vaulting deaths in 1983 were a major concern and immediate measures were taken by the National Federation of State High School Associations.  Beginning with the 1987 season all individual units in the pole vault landing area had to include a common cover or pad extending over all sections of the pit.   

         In 2001 there was a pole vaulting injury to a female college athlete.  The athlete was vaulting indoors, bounced out of the pit, and hit her head on the floor.  She had an epidural hematoma and a posterior skull fracture.  At the time of the accident it was not possible to determine the extent of any long-term disability.  There was one pole vaulting injury in 2005 and none is 2006.

        Whenever there is a pole vaulting death there are more proponents of eliminating the event.  The crux of the opposition appears to be the potential liability and also the lack of qualified coaches to teach the pole vault. Additional recommendations in the 1991 rule book stabilize the pole-vault standards so they cannot fall into the pit, pad the standards, remove all hazards from around the pit area and control traffic along the approach.  Obvious hazards like concrete or other hard materials around the pit should be eliminated.  In the National Federation of State High Schools Track and Field Rules Book, Section 4, Article10, it states as follows:  Hard or unyielding surfaces, such as but not limited to concrete, metal, wood or asphalt around the landing pad, or between the planting box and the landing pad, shall be padded or cushioned with a minimum of two (2) inches of dense foam or other suitable material.  It is also recommended that any excess material such as asphalt or concrete that extends out from beneath the landing pad be removed.

         Due to the numbers of pole vaulting injuries there have also been a number of recommendations stating that pole vaulters should wear helmets.  The National Federation of State High School Associations has made the following statement concerning pole vaulting helmet use:   The NFHS has been asked if it would be permissible for high school students to wear some type of helmet while pole vaulting and they stated that it would be permissible for an athlete to wear a helmet of his/her choosing without violating the NFHS rules.  A helmet designed exclusively for pole vault, the KDMax, was released in October 2004.  Six state high school associations already require some type of helmet for pole vaulters, and 30 states indicated on the 2004 NFHS track and field survey that they would support mandatory helmet use if a national standard was in place.  In the NCAA helmets will continue to be an option for pole vaulters.

        It has been estimated that there are approximately 25,000 high school pole vaulters annually.  If this number is correct, the catastrophic injury rate for high school pole vaulters would be higher than any of the sports included in the research.

        There have also been 23 accidents in high school track involving participants being struck by a thrown discus, shot put or javelin.  In 1992, a female athlete was struck by a thrown discus in practice and died.  In 1993, a track manager was struck in the neck by a javelin, but he was lucky and completely recovered from the accident.  In 1994, a female track athlete was struck in the face by a javelin and will recover. In 1995, a male athlete was struck in the head by a shot put during warm-ups and had a fractured skull.  In 1997, a male athlete was struck by a discus and died.  In 1998 a female athlete was struck by a discus and died, and a male athlete was struck in the head by a shot-put and recovered.  In 1999 a male athlete was struck by a javelin and a female athlete was struck by a discus.  In 2000 a junior high school athlete was struck in the head by a discus and has permanent disability.  In 2001 a high school athlete was struck in the cheek with a javelin during practice.  In 2002 there were three athletes struck by a shot putt and one by a discus.  In 2002 there was also a coach that was struck by a shot putt.  In 2004 a male track athlete was hit in the head with a shot putt and was in critical condition.  In 2005 a track athlete was impaled with a javelin in the shoulder.  In 2006 a male track athlete was hit inthe head with a javelin which went four inches into his brain.  He was very lucky and had a full recovery.   There have also been spectators struck by the discus during high school meets.   On June 23, 2005, a 77 year old official died after being struck in the head by a shot put while athletes were practicing for the US championships. Safety precautions must be stressed for these events in both practice and competitive meets with the result being the elimination of this type of accident.  The National Federation of State High School Associations put a new rule in for the 1993 track season that fenced off the back and sides of the discus circle to help eliminate this type of accident.  Good risk management should eliminate these types of accidents. These types of injuries are not acceptable and should never happen.

        The fatality in high school lacrosse during the 1987 season was associated with a player using his head to strike the opponent.  He struck the opponent with the top or crown of his helmet.  This technique is prohibited by the lacrosse rules and should be strictly enforced.  In 2002 a high school lacrosse player was also blocking and suffered permanent paralysis. Lacrosse has been a fairly safe sport when considering the fact that high school lacrosse has been involved with eight direct catastrophic injuries in twenty-four years.  A possible new area of concern is the recent lacrosse deaths being associated with players being struck in the chest with the ball and causing death (commotio cordis).  There have been five cases, two high school, three college, and one lacrosse summer camp in the past eight years.  Currently there is research being funded by the National Operating Committee for Standards in Athletic Equipment that is looking at chest protectors to help reduce commotio cordis fatalities. The lacrosse community will have to keep a close watch on these types of deaths and possibly carry out in-depth evaluations of these injuries.

        There was a female college lacrosse player in 1993 that was hit in the eye with a ball and had permanent vision damage.  In the spring of 2004 protective eyewear was required for all high school participants in states that follow NFHS rules, and for all competitors at the NCAA championships.  In 2005, the requirement will extend to the entire season for all NCAA teams.  Early reports indicate a major reduction in eye injuries for female lacrosse players.

        College spring sports are also associated with a low injury incidence.  Injury rates are slightly higher in lacrosse but the participation figures are so low that even one injury will increase the incidence rate dramatically.  It is important to point out that there have been nine college male and two female lacrosse catastrophic injuries during the past twenty-four years.  The college death in 2005 involved a male player being struck in the neck by a ball.  In a college club lacrosse game on October 15, 2005, there was a non-fatal catastrophic injury to a male participant.  He was hit with a point blank range shot off of his helmet.  The injury was a subdural hematoma and the athlete had surgery.  There has been questions concerning the particular helmet the player was wearing at the time.  It should be mentioned that there is general concern about concussion injuries in lacrosse, and according to a study from Temple University, female lacrosse players have the highest percentage of suffering a concussion during a game followed by women’s soccer.

        For the twenty-three four period from the fall of 1982 through the spring of 2006 there have been 1,031 direct catastrophic injuries in high school and college sports.  High school sports were associated with 147 fatalities, 350 non-fatal and 337 serious injuries for a total of 834.  College sports accounted for 22 fatalities, 61 non-fatal and 114 serious injuries for a total of 197.  During this same twenty-four year period of time there has been a total of 512 indirect injuries and all but eleven resulted in death.  Four hundred and fifteen of the indirect injuries were at the high school level and 97 were at the college level.  It should be noted that high school annual athletic participation for 2005-2006 includes approximately 7,159,904 athletes (4,206,549 males and 2,953,355 females).  National Collegiate Athletic Association participation for 2005-2006 was 398,616 athletes. There were 228,098 males and 170,518 females. 

        During the twenty-four year period from the fall of 1982 through the spring of 2006 there have been 139,669,551 high school athletes participating in the sports covered by this report.  Using these participation numbers would give a high school direct catastrophic injury rate of 0.60 per 100,000 participants.  The indirect injury rate is 0.30 per 100,000 participants.  If both direct and indirect injuries were combined the injury rate would be 0.90 per 100,000.  This means that approximately one high school athlete out of every 100,000 participating would receive some type of catastrophic injury.  The combined fatality rate would be 0.40 per 100,000, the non-fatal rate 0.25, and the serious rate 0.25.

        During this same time period there were approximately 7,624,555 college participants with a total direct catastrophic injury rate of 2.58 per 100,000 participants.  The indirect injury rate is 1.27 per 100,000 participants.  If both indirect and direct injuries were combined the injury rate would be 3.86.  The combined fatality rate would be 1.52, the non-fatal rate 0.83, and the serious rate 1.51. 

Female Catastrophic Injuries

        There have been a total of 107 direct and 57 indirect catastrophic injuries to high school and college female athletes from 1982-83 – 2005-2006, which includes cheerleading.  Seventy-eight of these were direct injuries at the high school level and 29 at the college level.  The 78 high school direct injuries included nine in gymnastics, 43 in cheerleading, five in swimming, four in basketball, six in track, three in softball, three in field hockey, two in ice hockey, one in lacrosse, one in soccer, and one in volleyball.  The 45 high school indirect fatalities included eleven in basketball, seven in swimming, five in track, six in soccer, seven in cross country, one in volleyball, one in water polo, and seven in cheerleading.  The 29 college direct injuries were associated with cheerleading(17), gymnastics(2), field hockey(3), soccer(1), skiing(1), ice hockey(1), track (pole vault)(1), equestrian(1), and lacrosse(2).  The nine college indirect fatalities included one in tennis, three in basketball, three in soccer, one in gymnastics, and one in volleyball.  Catastrophic injuries to female athletes have increased over the years.  As an example, in 1982-83 there was one female catastrophic injury and during the past 24 years there has been an average of 6.8 per year. A major factor in this increase has been the change in cheerleading activity, which now involves gymnastic type stunts.  If these cheerleading activities are not taught by a competent coach and keep increasing in difficulty, catastrophic injuries will continue to be a part of cheerleading. High school cheerleading accounted for 55.1% of all high school direct catastrophic injuries to female athletes (two males not included) and 58.6% at the college level (four males not included).  Of the 107 direct catastrophic injuries to high school and college female athletes from 1982-83 – 2005-2006, cheerleading was related to 60 or 56.1%.  The cheerleading numbers have been updated from previous reports.  Read the special section on cheerleading.

        Athletic administrators and coaches should place equal emphasis on injury prevention in both female and male athletics.  Injury prevention recommendations are made for both male and female athletes.

        Athletic catastrophic injuries may never be totally eliminated, but with reliable injury data collection systems and constant analysis of the data these injuries can be dramatically reduced.

SPORT                       FATALITY                 NON-FATAL             SERIOUS       TOTAL

Cheerleading*                      2                                      13                          28                  43

Gymnastics                           0                                        6                             3                    9

Track                                   1                                        1                             4                    6

Swimming                             0                                        4                             1                    5

Basketball                           0                                          1                              3                    4

Ice Hockey                          0                                         0                             2                    2            

Field Hockey                        0                                         3                            0                    3

Softball                               1                                          2                             0                     3

Lacrosse                              0                                         0                             1                     1

Soccer                                 0                                         1                             0                     1

Volleyball                           0                                           1                            0                     1

TOTAL                              4                                       32                            42                   78

* Cheerleading does not include two males

HIGH SCHOOL FEMALE INDIRECT CATASTROPHIC INJURIES

1982-83 – 2005-06

SPORT                       FATALITY                 NON-FATAL             SERIOUS       TOTAL
Basketball                            11                                    0                                  1               12
Swimming                               7                                    0                                  1                 8

Cheerleading                          7                                    0                                  0                 7

Cross Country                        7                                    0                                  0                 7

Soccer                                   6                                    0                                  0                 6

Track                                     5                                    0                                  0                 5

Volleyball                               1                                    1                                  0                 2

Water Polo                           1                                    0                                  0                 1

TOTAL                                45                                   1                                  2                48

COLLEGE FEMALE DIRECT CATASTROPHIC INJURIES

1982-82 – 2005-06

SPORT                       FATALITY                 NON-FATAL             SERIOUS       TOTAL

Cheerleading*                      1                                      5                              11                 17

Field hockey                         0                                      1                                2                   3

Lacrosse                              0                                      2                                0                   2

Gymnastics                           0                                      2                                0                   2

Equestrian                            1                                      0                                0                   1

Soccer                                 0                                      1                                0                   1

Ice Hockey                          0                                      0                                1                   1

Skiing                                   1                                      0                                0                   1

Track (Pole Vault)                0                                      1                                0                   1

TOTAL                               3                                     12                              14                 29

*Cheerleading does not include four males

COLLEGE FEMALE INDIRECT CATASTROPHIC INJURIES

1982-83 – 2005-06

SPORT                       FATALITY                 NON-FATAL             SERIOUS       TOTAL

Soccer                                 3                                      0                                  0                3

Basketball                            3                                      0                                  0                3

Tennis                                  1                                      0                                  0                1

Volleyball                             1                                      0                                  0                1

Gymnastics                           1                                      0                                  0                1

TOTAL                               9                                      0                                  0                9

Recommendations for Prevention
 

1. Mandatory medical examinations and a medical history taken before allowing an athlete to participate.
2. All personnel concerned with training athletes should emphasize proper, gradual and complete physical conditioning in order to provide the athlete with optimal readiness for the rigors of the sport.
3. Every school should strive to have a certified athletic trainer who is a regular member of the faculty and is adequately prepared and qualified.  There should be a written emergency procedure plan to deal with the possibility of a catastrophic injury.
4. There should be an emphasis on employing well trained athletic personnel, providing excellent facilities and securing the safest and best equipment available.
5. There should be strict enforcement of game rules and administrative regulations should  be enforced to protect the health of the athlete.  Coaches and school officials must support the game officials in their conduct of the athletic contests.
6. Coaches should know and have the ability to teach the proper fundamental skills of the  sport.  This recommendation includes all sports and not only football.  The proper fundamentals of blocking and tackling should be emphasized to help reduce head and  neck injuries in football.  Keep the head out of football.
7. There should be continued safety research in athletics (rules, facilities, equipment).
8. Strict enforcement of the rules of the game by both coaches and game officials will help reduce serious injuries.
9. When an athlete has experienced or shown signs of head trauma (loss of consciousness, visual disturbance, headache, inability to walk correctly, obvious disorientation, memory loss) he/she should receive immediate medical attention and should not be allowed to return to practice or game without permission from the proper medical authorities.  It is important for a physician to observe the head injured athlete for several days following the injury.
10. Athletes and their parents should be warned of the risks of injuries.
11. Coaches should not be hired if they do not have the training and experience needed to teach the skills of the sport and to properly train and develop the athletes for competition.
12. Weight loss in wrestling to make weight for a match can be dangerous and cause serious injury or death.  Coaches should be aware of safety precautions and rules associated with this practice.

        All of the information has been thoroughly checked and the data cleaned.  Some of the numbers in Tables I - XXIV have been changed due to this process.  All of the data in this report now meet the stated definition of injury for high school and college sports.  It is important to note that information is constantly being updated due to the fact that catastrophic injury information may not always reach the center in time to be included in the current final report.  The report includes data that is reported to the NCCSIR by the NCAA, the NFHS, a national newspaper clipping service, colleagues, coaches, and athletic trainers.  There may be additional catastrophic injuries that are not reported to the Center.

1.  TATOR CH, EDMONDS VE:  National Survey of Spinal Injuries in Hockey Players, Canada
     Medical Association 1984; 130:  875-880.

    High school and college case studies in football are not duplicated for this report.  They are included in the football reports on the www site – www.unc.edu/depts/nccsi.

HIGH SCHOOL

    A 17 year-old male high school soccer player died on October 11, 2005, when he was playing goalie during a game. In trying to block a shot he dove for the ball and it struck him in the throat.  He later died at the hospital.

    An 18 year-old male high school soccer player collapsed on the sideline during a game on September 18, 2005.  He later died and cause of death was hypertrophic cardiomyopathy.

    A 17 year-old male high school soccer player collapsed and died during the first day of practice on January 18, 2006.  He was running his second warm-up lap on the track when he collapsed.  Cause of death was unknown at this time, but is expected to be heart related.

    A 15 year old male and three friends were attempting to move a soccer goal when it tipped over and the crossbar hit him in the head causing death.

FIELD HOCKEY

COLLEGE

    A 21 year-old female college field hockey player was injured on September 25, 2005, while attempting to trap a ball.  Impact occurred with her finger between the ball and the stick, and she sustained the avulsion of the distal half of her 5^th phalanx of right hand.  She was the flyer during a short corner.  She had no glove or protective covering for her hands/fingers.

     A 16  year-old male ice hockey player suffered a severe cut of his jugular vein when he was cut by the skate of the opponent. He was playing defense when a forward from the opposing team was hit , went head over heels and struck the defenseman in the neck with his skate.  There was a full recovery.

A 15 year-old female high school swimmer collapsed at the end of her race and later died.  An AED was available but was not used because she was breathing at the time.  Death was heart related.

HIGH SCHOOL

    A 16 year-old male high school basketball player collapsed during  JV game on 12/20/05 and died while on the way to the hospital.  Death was heart related.

    A 16 year-old male high school basketball player collapsed during practice on 12/2/05 and later died.  He suffered from asthma and often used his inhaler during practice.  Cause of death was unknown.

    A 14 year-old female high school basketball player collapsed and died on 11/15/05 during a practice. She had a physical exam the morning before her death.  Practice consisted of conditioning drills.  Death was heart related.

    A male high school basketball player collapsed and died during tryouts in October 2005.  A preliminary autopsy revealed cause of death as an asthma attack.

    A 15 year-old male high school basketball player collapsed and died while warming-up for a game.  Cause of death was unknown at this time.

    A male high school basketball player collapsed and died on January 6, 2006.  He collapsed on the sidelines.  Death was heart related.

    2002 Update – A 15 year-old male high school basketball player collapsed and died during a rest break at practice on December 7, 2002.  Cause of death was heart related.

    2004 Update – A 16 year-old male high school basketball player collapsed and died during a shooting drill at practice on January 12, 2004.  Cause of death was heart related.

    2004 Update - A 15 year-old male high school basketball player collapsed and died during a game on January 16, 2004.  Cause of death was heart related.

    2005 Update – A high school male basketball player died following a game on January 15, 2005.  No other information was available.

COLLEGE

    A 22 year-old female college basketball player collapsed and died on 9/26/05.  Cause of death was caused by a pulmonary blood clot.  She was not feeling well when she arrived the gym and had not been working out or practicing at the time of her collapse.

    A female college basketball player collapsed and died during a team run on September 1, 2005.  Cause of death was unknown.

    A male college basketball player was injured while going for a loose ball during practice in January 2006.  He suffered a cervical vertebra fracture and at the time of this writing was paralyzed.

HIGH SCHOOL

    An 18 year-old male high school wrestler collapsed between matches on January 14, 2006.  He had no pulse or heart beat when an athgletic trainer began CPR.  An AED was used minutes later and the player began breathing.  There was a full recovery.

    A 16 year-old male high school wrestler fractured a cervical vertebra on January 7, 2006, during a match.  He was taken down from a standing position and his opponent landed on his head/neck.  He was taken off life support on January 27, 2006 and died.

    A 14 year-old high school male wrestler died after collapsing after a captain’s practice. It is known as a captain’s practice due to coaches not allowed to attend until the season begins.  The accident took place on November 11, 2005.

    2000 Update – A 16 year-old high school male wrestler was paralyzed from the waist down during a wrestling match in January 2000.  He was injured while trying to get out of hold called the Guillotine.

    2002 Update – A 15 year-old male high school wrestler was injured in October 2002 during a wrestling tournament.  He received a neck injury and is quadriplegic.

    A male college club team lacrosse member was struck in the helmeted head by a hard shot during a game on 10/15/05.  The shot was at point blank range and the player was unconscious after the hit.  He was taken to the hospital by ambulance where he had surgery.  He regained consciousness after the surgery.  He was very lucky that medical care was readily available.  He will recover from the injury.

    A 21 year-old male lacrosse player collapsed during off-season conditioning on 10/31/05.  He had completed two of four ¼ mile runs.  He later died at the hospital.  He had a pre-season physical exam.  Cause of death was unknown at this time, but was expected to be heart related.

HIGH SCHOOL - None

COLLEGE – 2000 Up-Date

    A male college baseball player was injured during an infield drill on February, 5, 2000.  In a mix-up of where the ball was coming from he was hit in the eye by a throw from the catcher.  He had permanent damage to the eye.

HIGH SCHOOL

A 15 year-old male high school track athlete was injured in May 2006 when he was hit in the head by a javelin. The javelin did not do any damage and the athlete recovered.

HIGH SCHOOL

    A 15 year-old female volleyball player went into cardiac arrest after a volleyball practice in December 2005.  She had some brain damage due to the loss of oxygen.  At the present time she has some disability.                                                                      

GOLF

HIGH SCHOOL

    A 14 year-old male high school golfer was struck by lightning during a tournament in September 2005.  He was struck in the head.  Apparently there was no time to take shelter.  He was given CPR and started to breathe.  He has recovered after a hospital stay.  Two other participants were hospitalized and were in stable condition, and a fourth was treated and released.

HIGH SCHOOL AND COLLEGE

NONE

HIGH SCHOOL AND COLLEGE

NONE
 

HIGH SCHOOL AND COLLEGE

NONE

HIGH SCHOOL AND COLLEGE

 NONE

HIGH SCHOOL AND COLLEGE

NONE
 

         The National Center for Catastrophic Sports Injury Research has been collecting cheerleading catastrophic injury data during the past twenty-four years, 1982-83 – 2005-2006. There were seven high school cheerleading catastrophic injuries during the 2005-2006 school year.   The direct injuries included one death, one disability injury, and four serious injuries.  The indirect injury was a death.  College cheerleaders were involved with one accident during the 2005-06 season.   A cheerleader fractured a cervbical vertebra  during a routine and had a full recovery.

1. In the early 1980's a female college cheerleader fractured her skull after falling from a human pyramid.  She recovered and returned to cheerleading after several weeks in the hospital.
2. In 1983 two female college cheerleaders received concussions within a period of five days in the same gymnasium.  One struck her head on the floor after falling from a pyramid and the second cheerleader struck her head on the floor after falling backward from the shoulders of a male partner.
3. In the summer of 1984 a female high school cheerleader was injured at practice when she fell from a pyramid.  She was partially paralyzed.
4. A male college cheerleader was injured in a tumbling accident during a basketball game in December 1983.  He fractured and dislocated several cervical vertebrae and was paralyzed.  He received his injuries after diving over a mini-trampoline and several cheerleaders.  The stunt is called a dive into a forward roll.  He has made progress and can now walk unaided for several blocks and is able to feed himself.
5. In 1985 a female high school cheerleader was paralyzed from the chest down after attempting a back flip off the back of another cheerleader.
6. In 1985 a female college cheerleader fractured her skull after a fall from the top of a pyramid striking her head on the gym floor.  She was in critical condition for a period of time but has made progress and is back in school.  She is now involved in occupational therapy.
7. A male college cheerleader was paralyzed after a fall in practice.  He was attempting a front flip from a mini-trampoline.  He dislocated several cervical vertebrae and is now quadriplegic.
8. In 1986 a female college cheerleader fell from a pyramid and was knocked unconscious after striking the floor.  Her status was unknown at the time of this writing.
9. In 1986 a college female cheerleader died from injuries suffered in a cheerleading accident.  She suffered multiple skull fractures and massive brain damage after falling from the top of a pyramid type stunt and striking her head on the gym floor.
10. In 1987 a 17 year old high school cheerleader fell from a pyramid.  She was tossed into the air by two other cheerleaders and was supposed to flip backwards and land on the shoulders of two other girls.  Her spinal cord was not severed but she is paralyzed from the waist down.
11. During the 1987-1988 school year a female cheerleader suffered a fractured collarbone, a damaged ear drum and a basal skull fracture.  She was practicing a pyramid and was six feet off the gym floor with no spotters.  She has suffered partial hearing loss and has to wear special glasses for reading.
12. In January 1988 a female cheerleader fell from a pyramid and landed on her face and shoulder.  She suffered a fractured collarbone and head injuries.  She was in a light coma in the hospital but complete recovery is expected.
13. In January 1989 a high school cheerleader fractured a cervical vertebra after falling from a mount in practice. She will recover with no permanent disability.
14. On July 11, 1989 a 16 year old high school cheerleader fractured a cervical vertebra and is quadriplegic.  She slipped while doing a series of back flips on damp grass.
15. On March 10, 1990 a female high school cheerleader was thrown into the air by two other cheerleaders.  She fell to the floor onto her neck and was in the hospital for one week.  The routine was called a basket toss.  She has recovered and is back in school.
16. On March 1, 1990 a 21 year old male college cheerleader was injured at practice.  In attempting to do a back flip he hit his head against a wall.  He was taken to the hospital by ambulance.  He has since recovered and the injuries were not serious.
17. In June of 1991 a 15 year old cheerleader suffered injuries to the head.  She was struck in the head by her falling partner and also after striking the ground.  The injury took place in a cheerleading camp.  The cheerleader was taken to the hospital but her condition is not known at this time.
18. A middle school cheerleader was injured in October 1991 and died the next week.  She fell from a double level cheerleading stance during practice.  She hit her head on the gym floor.
19. A 20 year old college cheerleader suffered a head injury while practicing a cheerleading stunt in which she was thrown into the air but was not caught by her teammates.  She landed on the gym floor.  She was in critical condition but has been upgraded to serious and is expected to recover.
20. In May of 1992 a college cheerleader was doing a tumbling sequence when she landed on her back and fractured T-12.  The practice was not supervised.  There was a complete recovery.
21. A high school cheerleader was injured during a basketball game doing a back handspring tuck.  She hit her head on the floor.  She had surgery to remove a blood clot.  Her condition is not known at this time.
22. A high school cheerleader was tossed in the air during a routine, was not caught, and      fell hitting her face on the basketball floor.  She remained motionless for approximately 30 minutes.  She is expected to recover. The accident happened in December 1993.
23. A high school cheerleader fell and hit her head on the basketball floor while being lifted by the feet by two other cheerleaders.  She was taken to the hospital for observation and is expected to recover.  The accident happened in December 1993.
24. A college cheerleader was doing a tumbling run when he lost control and fell on his head.  He fractured a cervical vertebra and is expected to recover.  The accident happened in August 1994.
25. A college cheerleader was injured in a cheerleading competition in April 1994.  She struck another cheerleader while doing a backflip and fell to the floor.  She suffered a fractured cervical vertebra and is expected to recover.
26. A female college cheerleader received a fractured skull during warm-ups for a performance of stunts for a Christmas parade.  She was injured in a four man back tuck basket toss.  She landed on her head.  There was no permanent disability, but she was in rehabilitation for memory.  The injury occurred in November 1994.
27. A high school cheerleader was kicked in the face by a teammate who was falling from the top of a pyramid.  The injured cheerleader suffered convulsions and was transported to the hospital. She was in stable condition and was expected to recover.  The injury occurred in January 1995.
28. A high school cheerleader received a closed head injury in March 1995 during a basket toss stunt.  She landed on a hard rubberized basketball court.  There was no permanent disability.
29. A college cheerleader was paralyzed in April 1995 after being injured while performing a double flip during a basket toss.  At the present time she is quadriplegic.
30. A high school cheerleader was injured during a stunt when a fellow cheerleader fell on her head.  She has had permanent medical problems since the accident.  This was an update from November 1993.
31. In 1997, a high school cheerleader suffered a 15 foot fall.  She had spinal cord trauma and is paralyzed.
32. A college cheerleader was injured in 1997 during a tumbling routine and is now quadriplegic.  She was attempting a back hand spring into a single back tuck during practice and landed on her head.
33. In 1997, two chee