Clin Rheumatol (2013) 32:463–467
DOI 10.1007/s10067-013-2188-4
ORIGINAL ARTICLE
“Extreme” or tariff sports: their injuries and their prevention
(with particular reference to diving, cheerleading,
gymnastics, and figure skating)
E. C. Foley & H. A. Bird
Received: 12 January 2013 / Accepted: 25 January 2013 / Published online: 16 February 2013
# Clinical Rheumatology 2013
Abstract The interface between sports medicine and
performing arts medicine is closest for “tariff” sports, where
the sportsperson can select their own programme of varying
difficulty with the more complex skills carrying potential for
higher marks. Inevitably, some performers over-reach them-
selves. Examples of injuries and prevention strategies to avoid
such injuries are discussed in a preliminary analysis of four
sports: diving, cheerleading, gymnastics, and figure skating.
Keywords Tariff sports . Injury . Injury prevention
Introduction
Sports medicine is an established field in some countries
with specialist training schemes and even degrees and
diplomas in that specialty. Perhaps because of this, and
because of the ample funding, some areas of sport, for
example American Football in the USA and Association
Football in the UK enjoy unprecedented wealth. The aver-
age professional football club in the UK might retain doc-
tors, physiotherapists, and orthopedic surgeons among
others. By contrast, only the largest ballet and contemporary
dance companies can afford a physiotherapist or part-time
physiotherapist and only a limited number of orchestras,
notably in the UK and Holland, have access to a dedicated
general practitioner.
E. C. Foley (*)
Trinity Laban Conservatoire of Music and Dance, Greenwich,
London, UK
e-mail: Elaine.F11@edu.trinitylaban.ac.uk
H. A. Bird
Pharmacological Rheumatology, University of Leeds, Leeds,
London, UK
H. A. Bird
Performing Arts Medicine, University College, London, UK
Some sports are less well endowed and among these,
some relate particularly to performing arts and performing
arts medicine. For sports such as athletics and swimming,
the requirements for the body are well defined and not
subject to significant change between competitors. By con-
trast, “tariffed” sports are more closely related to performing
arts, notably dance, in that the requirements upon the athlete
vary considerably. Marks are awarded both for technique,
but also according to the difficulty of the move. An athlete
can choose to build up a high score, either by performing a
large number of maneuvers adequately or by performing a
small number of maneuvers extremely well. This has the
potential to place significant strains on the body as compet-
itors compete using routines of ever-increasing difficulty.
For this reason, it seems justifiable to include a paper of
tariff sports in a themed-issue devoted to performing arts
medicine. This paper seeks to describe injuries in such
sports and attempts to recommend strategies for prevention.
Space restricts discussion to four such sports; diving, cheer-
leading, gymnastics, and figure skating.
Diving
Diving is a sport where the athlete embodies many of the same
skills as a dancer or gymnast as they jump into the water from
either a springboard (1 or 3 m high) or platform ledge (10 m
high). Before a competition, the diver creates a list describing
each dive, which cannot be changed or altered except in the
most exceptional circumstances. Dives are classified into six
groups: forward, backward, inward, reverse, twist, and hand
or armstand. While jumping in one of these directions, the
diver assumes a position of tuck, pike, straight, or free.
Judges score dives based on the approach, flight, and entry
by judging the diver’s height in the air, distance from the board,
angle of entrance to the water, and the amount of splash. Also,
the diver must look strong and in control with the legs touching
464
and the feet pointed. The degree of difficulty, determined by the
complexity of the acrobatic combination, is what guarantees
higher scores—though this can also enhance the risk.
Despite the many intricate dives performed by compet-
itors, their injury frequency is low. Divers train with tram-
poline spotting rigs and twisting and tumbling belts.
Sometimes, they train on a sprung floor in a gymnastics
gym. In order to prevent injury, a diver often orders their
dives such that an easier dive precedes a more difficult one.
This helps to sustain confidence levels.
Worldwide, diving is the sport with the highest frequency
of catastrophic injury, mainly due to spinal trauma affecting
the neck, often with neurological involvement [1, 2]. To some
extent, this is artefactual since many of these injuries occur in
unsupervised situations outside the sporting arena. Hitting the
bottom of an unfamiliar private pool or beach is the common-
est scenario. Typically, this results in a fracture between C4
and C6. Alcohol often contributes in the recreational setting.
The two main contact injuries are “smacking” the water
and hitting the diving board. “Smacking” is essentially a
belly flop where the diver’s body lands parallel to the water.
This may cause welts and bruising. Training to avoid this
can include the use of a harness on dry land as new dives are
learned and the use of a bubble machine on water to reduce
surface friction. Hitting the diving board is of more concern
and usually involves the hands or feet, which sometimes
causes fracture. Exceptionally, the skull strikes the board,
which is more dangerous.
More subtle overuse injuries afflict the wrists, shoulders,
and back because of the repetitive nature of the sport, most
dives using similar muscle groups. “Flat hand” entry to the
water and the pressure of handstands on the board both
aggravate the overuse injury at the wrists (Fig. 1). Sometimes,
wrist guards or taping are of preventative value. Exercises that
Fig. 1 Tom Daley, British Olympic diver, holds a handstand on a 10-m
platform. The potential strain on the wrists is evident, even before
entering the water. Photo credit: Getty Images/July 27, 2011 (http://
w w w. b a l t i m o r e s u n . c o m / n e w s / p h o t o s / b a l - a f p - g e t t y -
50473353620110727174706,0,7005063.photo)
Clin Rheumatol (2013) 32:463–467
improve core support at the back and that strengthen the
shoulders through weight machines or body resistance work
also reduce the susceptibility to such overuse.
Cheerleading
Competitive cheerleading is executed through a timed rou-
tine, within a specific performance area, in front of judges
who evaluate the tumbling, dance, jumps, stunting, and
cheering of the cheerleaders. Guidelines for the routines
and the skills permitted within those routines are split into
divisions. Performing a technique outside of the division
rules will result in penalty. Each cheerleading competition
will abide by different rules with some being stricter than
others in terms of forbidding “illegal” stunts that pose po-
tential risks to the performers. Each team must aim for
different marking criteria in the different competitions and
thus practice a wide variety of skills and stunts.
Cheerleading is notorious for being one of the most
dangerous sports, even though its status as an official sport
is often questioned. This uncertain categorization can leave
cheerleaders inadequately supported in the realm of safety.
Even though all competitions are performed on a carpeted
sprung floor, most cheerleaders rehearse in gymnasiums or
outside on grass or on a Tartan track with or without a
competent “spotter”. This can be seen as a problem then,
when certain levels of cheerleading require complicated
stunts. For example, in America, a level 5 all-star cheerlead-
er would be encouraged to perform a tumbling pass with a
full twist in order to maintain a competitive edge.
Most commonly injuries for cheerleaders occur in the
ankles and wrists. Both the flyer (the person being lifted or
tossed) and the bases (people lifting, tossing, and catching the
flyer) are at risk of experiencing overloads of force upon their
joints throughout a routine (Fig. 2). For example, a popular
stunt today called a “tick-tock” is when the flyer is lifted into
the air with support on only one foot/ankle while the other is
folded up to the knee in passé (or held in extension). Then,
with a push from the bases, the flyer suspends in the air just
long enough to switch positions of the legs, with the bases
then catching and supporting the opposite foot/ankle while the
flyer continues to balance unilaterally. This stunt not only
requires extreme balance, coordination, and cooperation from
the team but also complete confidence in each other. Fear or
uncertainty in the middle of a stunt, causing any member of
the team to freeze up, can cause serious injury.
Also, there is psychological pressure on cheerleaders to
“go to the max” by seeking the highest jumps and the most
complex tumbling passes for fear that they will be otherwise
positioned in the back of the group during performances.
Considering the costs of maintaining membership to a
cheerleading club and the hard work and dedication required
Clin Rheumatol (2013) 32:463–467
Fig. 2 Jacksonville University cheerleaders performing a liberty stunt.
This could also be the beginning movement of a tick tock. The weight
of the whole body is directed through a single ankle, the stability of
which is entirely dependent on the coordination of all three cheer-
leaders giving support. Photo credit: http://en.wikipedia.org/wiki/File:
JU_Cheerleaders.jpg
at summer conditioning and for the yearlong competition
preparation, nobody wants to perform in the back where
there is less chance of being seen.
Sadly, cheerleading, nowadays arguably extreme gym-
nastics but without the regulation of that sport, accounts
for 63 % of all direct catastrophic injuries to female high
school students and 56 % of injuries at college level in the
USA. Only 29 American high schools recognize cheerlead-
ing as a sport, which leaves much to be desired in terms of
official certifications a coach must obtain in order to direct a
group of students through complex stunts and tumbling
passes [3].
Typical injuries include fractures and dislocations, trau-
matic brain injury, spinal cord injury, lung and heart trauma,
and torn tendons as well as more trivial sprains and strains.
It is no surprise that the American Association of Cheer-
leading Coaches and Administrators are now taking an
active lead to improve safety through the provision of guide-
lines for acrobatics and stunts, even though these are not yet
mandatory [4].
Gymnastics
There are several types of gymnastics, artistic and rhythmic
perhaps the most common although these are quite different
sports.
465
Artistic gymnastics comprises four events for women
(floor exercise, vault, asymmetric bars, and balance beam)
and six events for men (pommel horse, still rings, vault,
parallel bars, high bar, and floor exercise). A gymnast’s total
performance is marked with an “execution” score and a
“difficulty” score. Scoring begins at a starting value com-
prised of the difficulty level and the composition require-
ments. The difficulty score evaluates the combination, order,
and complexity of the skills performed with deductions
occurring depending on the degree of success (or lack
thereof) displayed in its execution.
Rhythmic gymnastics utilizes five pieces of apparatus
(ball, ribbon, rope, hoop, and clubs) on a carpeted floor area
with a combination of tumbling skills and dance. Scores are
taken out of 30 with artistry, difficulty, and execution all
evaluated. Each gymnastics event requires a high degree of
balance, flexibility, strength, and coordination.
Injuries often occur due to a continue-at-all-cost mentality
that drives gymnasts to power through important competitions
on broken bones or torn muscles. Performing with aches, pain,
soreness, and bruises is “part of the game” and gymnasts try to
put it out of their mind unless it is something they consider to
be beyond their coping threshold. This predisposes many
athletes to injuries of fatigue or overuse.
The injury risk in gymnastics is greatest with artistic
gymnastics or variants of this such as tumbling. The body
is often moving rapidly at extreme height (Fig. 3), often
inverted with a risk of serious head or neck injury some-
times leading to quadraplegia. Gymnastics is the second
leading cause of catastrophic and serious traumatic injuries
in female athletes. Falls from high pieces of apparatus have
occasionally caused fatalities through head injuries.
Other injuries such as those of the wrist or ankle occur
across the whole spectrum of gymnastics, including rhyth-
mic. Stress fractures of the leg occur especially in adolescent
females who are constantly impacting on hard surfaces in
events such as vault or tumbling. The age range of 11–15,
especially for those training for 8 hours a week or more,
Fig. 3 US gymnast Gabrielle Douglas performing in the artistic gym-
nastics women’s individual all-around competition at the 2012 Sum-
mer Olympics. The active oversplits are entirely dependent upon the
strength of the contributing muscles, strength here more crucial than
flexibility. Photo credit: AP Photo/Gregory Bull (http://photos.syracuse.
com/syracusecom_photo_essays/2012/08/photo_essay_a_last_look_at_
the.html#photo-11430714)
466
coincides with the peak incidence of injuries, possibly be-
cause this is the period of growth spurts with inevitable
stretching of the ligaments, making them vulnerable, until
developing muscular control catches up [5].
There is debate on whether the spondylolisthesis often
found in gymnasts results from the constant hyperextension
of the spine that is a feature of this sport or whether it reflects a
selection bias, those with the inherited spondylolysis
performing particularly well at the sport [6]. Close observation
may be required for those falling into the former group.
Options for prevention of injury include adherence to
basic safety precautions, training with a highly qualified
coach who specializes in acrobatics or gymnastics safety
training and is trained in cardiopulmonary resuscitation as
well as the use of appropriate mats and safety aids.
Figure skating
Competitive figure (artistic) skating is a highly technical
skill involving jumps, spins, footwork, dancing, and some-
times even acrobatics on ice skates. Competitions include
skaters performing either solo, in pairs, or in groups and
require the execution of advanced maneuvers either as part
of a required program or with more freedom (Fig. 4).
The judging system, designed by the International Skating
Union, is extremely technical to avoid inherent subjectivity.
Technical marks, judged by a specialist with video replay, are
awarded for each skating element. The number and kind of
elements in a skating program depends on the level of the
competition. Each skating program contains certain compo-
nents: skating skills, transitions, performance/execution, cho-
reography, and interpretation. Additionally, judges evaluate
the height of jumps, speed of skating, and amount of ice
covered to derive the overall score.
Fig. 4 Maxim Kamianchuk lifting Tatiana Volosozhar during the
International Skating Union European Figure Skating Championships.
Core support and strength of the left shoulder are crucial in the male
lifter though in the event of loss of this balance, both performers will be
injured. Photo credit: http://www.dailymail.co.uk/sport/article-
2092197/Sports-pictures-day-January-26.html
Clin Rheumatol (2013) 32:463–467
Many injuries in ice skating occur due to overuse with
inadequate footwear. Haglund’s syndrome (pump bump)
and lace bite (sharp pain and pressure along the extensor
hallucis tendon) develop with new boots that are too stiff or
laced too tightly. Because competitions occur throughout the
year, it is hard to implement the constructive rest periods
that often help to keep athletes injury free [7]. Although
there is semblance of a “season”, skaters and their coaches
will tend to work on new moves out of season.
Comprehensive surveys of injuries in this sport are avail-
able [8–10]. Some of these [11] deal with pairs skating as
well as ice dancing where the demands of the choreographer
predominate over a tariff of moves as in the sport.
Unsurprisingly, the ankle is most frequently involved, the
lower limb more than the upper and chronic overuse injuries
are surprisingly common, often accounting for more disabil-
ity than acute injuries. Tibial tendinosis, enthesitis, and
patellar stress syndrome are all common. In general, pairs
skating accounts for more injuries than solo skating and is
the main cause of the rare head injury because of the lifts
involved. Males seem to be more susceptible to injury than
age-matched females of comparable experience.
Certain risk factors also emerge from these studies. Excess
pronation tends to in young skaters on landing and needs
correction. Tight lumbodorsal fascia and tight hip flexors tend
to predispose to low back pain, which in any case is more
common in those with a lordotic lumbar spine. There is a
suspicion that unilateral sacro-iliac symptoms may be a spe-
cific feature of this sport [12], attributable to repetitive jump
landings on the single leg (in gymnastics most landings are
more evenly balanced) though there is also a high incidence of
mild spinal scoliosis in skaters which could also contribute
through a slight difference in leg length [9].
Conclusion
This group of tariffed sports, by their nature, lead to exces-
sive demands being placed on the bodies of competitors as
they are tempted to compete with moves that procure them
more marks but which place them at greater risk of injury.
Certain injuries that are peculiar to a particular sport are
predictable. Intrinsic factors that might predispose, such as
mal-alignments, leg length discrepancy, decreased flexibili-
ty, and excessive joint laxity which is often especially ad-
vantageous in this group of sports can be identified and
corrected. The issues are similar to those affecting the
hypermobile dancer, discussed in the previous article [13]
so management has much in common.
Several strategies for the prevention of injury emerge.
Coaches might suggest restraint when an athlete’s ambitions
exceed their capabilities. There is a need for closer interac-
tion between coaches and sports such that doctors with
Clin Rheumatol (2013) 32:463–467
expertise in sports medicine might advise national sporting
bodies, the regulations thereby derived made mandatory
rather than voluntary. There is also a need for better educa-
tion of both coaches and athletes who should be provided
with training regimens that reduce the risk of the commonest
injuries associated with their particular sport. Finally, atten-
tion to scoring guidelines in these tariffed sports might
reduce the risk of enthusiastic performers competing with
moves for which they have not yet acquired the technical
competence.
Acknowledgments We are grateful to the many sportspersons and
sports coaches from each of these sports, who have provided us with
much helpful information.
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