An October report from the Journal of Pediatrics reveals cheerleading has the highest rate of catastrophic injuries for female athletes.

From All-Star to high school squads, it's often a mix of gymnastics and mounting, but high performance routines can come with risks.

"I've seen people that are the basket or the catchers get concussions from being kicked in the head, I've seen a vast array," Dr. Joe Congeni says, director of sports medicine at Akron Children's Hospital. 

"The one we worry about the most, is when you're mounting a two person mount, or even in college a three level mount, that's a pretty significant distance of a fall and that's where some of the catastrophic injuries are concerning to us," he says.

While relying on self-reporting injuries is typical, medical experts worry that too many concussions are going unreported.

"Because the symptoms are subtle, because maybe they just don't feel right and have a headache and other things, it's easy to blame it on other things and not be sure a concussion really took place," Congeni says.

Congeni says several studies show as high as 80 percent of initial sports-related concussions fall through the cracks.

Recently, the Journal of Pediatrics studied 138 junior and senior high school cheerleaders who suffered concussions. The findings concluded that 33 percent did NOT report increased symptoms related to their injuries. 

Injuries have soared since the 80's. The U.S. Consumer Product Safety Commission's statistics show more than an estimated 4,000 cheerleaders made visits to an ER in 1980. In 2007, it was close to five times that amount, at more than 26,000.

At Lakeview High School's in Stoneboro, Pa., mandatory concussion intervention training is required for coaches each year. Each cheerleader must undergo cognitive testing for medical reference.

"We take that baseline and then use it if they do get a concussion, just to see when we can actually get them back participating," Brie Simons says, Lakeview High School's athletic director and trainer.

Post-concussion testing is recommended by medical experts. In the Journal's report, a doctor from Vanderbilt University School of Medicine concluded that the use of ImPACT testing (post-concussion assessment and cognitive testing), would result in "an increased capacity to detect and measure post-concussive abnormalities in cheerleaders compared with symptom assessment alone".