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General Medical Conditions: Case Reports

Horseback Riding-Related Vertebral Compression Fracture from Walking in Women with Low Bone Mineral Density

Reports of Two Cases

Oh, Jeehae MD; Oh, Hyun-Mi MD; Lee, Jong In MD, PhD

Author Information
doi: 10.1249/JSR.0000000000000221
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Introduction

Horseback riding is a popular recreational activity worldwide. With increasing emphasis on exercise and recreation, horseback riding is becoming more popular because it involves the entire body and helps physical development by improving balance and flexibility (11,18).

Horseback riding and related activities have distinctive features that predispose the rider to the risk of injury. Thomas et al. (21) found that 102,904 (35.7/100,000) people with nonfatal horse-related injuries were treated in emergency departments in the United States between 2001 and 2003. Boran et al. (5) reported that equestrian events were the most common cause (41.8%) of sports-related spinal injuries in Ireland over a 10-year period. However, mild sports-related injuries in amateur and beginner horseback riders have received little research attention. Herein, we present two cases of compression fracture occurring after riding in middle-aged female amateur horseback riders with low bone mineral density (BMD).

Case Reports

Case 1

A 44-year-old woman presented with a 4-month history of pain in the midthoracic area. She also reported a history of hypercholesterolemia and total hysterectomy without adnexectomy due to myoma 1 year ago. She took riding lessons once a week for 1 month. As a beginner, she rode the horse only at a slow walk for 30 to 40 min. At the end of the fourth lesson, she felt pain in the upper back, and she could not participate in riding lessons for 4 months. There was no trauma history. Physical examination revealed tenderness in the midthoracic area. Neurological examination findings were within normal limits. A radiograph of the thoracic spine showed a T7 compression fracture. Focal uptake was observed at the T7 vertebral body on a bone scan. Magnetic resonance imaging (MRI) confirmed the diagnosis of a mild benign compression fracture at T7 (Fig. 1). Under suspicion of osteoporosis, the patient underwent BMD testing. Her spinal T-score was −1.9, compatible with osteopenia. Therefore, the clinicians prescribed calcium and vitamin D supplements and recommended that she refrain from horseback riding and trunk flexion exercises for several months.

Figure 1
Figure 1:
(A) Sagittal T1-weighted MRI without contrast demonstrating decreased signal intensity and height loss in the T7 vertebra. (B) Sagittal T2-weighted MRI without contrast showing increased signal intensity and height loss in the T7 vertebra, suggesting old vertebral compression fracture.

Case 2

A 49-year-old woman presented to our clinic with upper back pain for 1 month. She had a history of hyperlipidemia, osteoporosis, and regular menstruation. She decided to learn how to ride a horse to control her body weight and improve her lipid profile. She reported back pain that was gradually aggravated after horseback riding; the pain started at the level of the midthoracic spine and radiated to the area under the scapula on both sides, worsening with trunk-twisting motions. She began horseback riding for 1 h every weekday for 2 months. Shortly before her presentation, she rode the horse at a fast pace but did not attempt to jump any obstacles. There was no other possible precipitant of the injuries. A bone scan revealed increased uptake in T6, which was suspicious of fracture. MRI confirmed an acute T6 compression fracture (Fig. 2). The patient was treated with bisphosphonate and calcium and vitamin D supplements, and an orthosis was prescribed. In addition, she was advised to avoid horseback riding and trunk flexion exercises for several months.

Figure 2
Figure 2:
(A) Sagittal fat suppression T2-weighted MRI without contrast demonstrating increased signal intensity and height loss in the T6 vertebra. (B) Sagittal fat suppression T1-weighted MRI with contrast enhancement showing increased signal intensity and height loss in the T6 vertebra, suggesting recent vertebral compression fracture.

Discussion

Equestrian activities encompass a wide range of recreational activities enjoyed by professionals and amateurs of different ages. Horse racing, harness racing, dressage, trail riding, training on a track, pony club riding, and simple pleasure riding are common riding pursuits. Opportunities for injury arise not only during riding, but also during many nonriding activities, such as training, grooming, handling, saddling, shoeing, and feeding of the horse. Horseback riding has several potential risk factors. A horse can weigh up to 500 kg, move at speeds of 65 km·h−1, elevate the rider 3 m above the ground, and act unpredictably and independently of the rider at any time (3,8,13,14).

A recent review suggested that the overall rate of injury due to horseback riding is relatively low, but that the rate of severe injury is higher than those for American football and motorcycle and automobile racing (4). One study found that equestrian sport-related injuries of admitted patients were severe and that 45% of these patients required surgical intervention (9).

The most common horse-related accident is falling from the horse, resulting in spinal fracture caused by axial forces exerted through the rump and transmitted through the spine (10). An increased axial load on the spine, which is a weight-supporting structure, can cause problems.

A limited number of studies have examined back pain due to horseback riding. Kraft et al. (12) investigated the structural causes of back pain in horseback riders by assessing morphological changes in the lumbar spine using MRI. They postulated that recurrent impact forces on the lumbar spine and significant leveraging of the lower back cause pain. They concluded that the major reasons for low back pain in horseback riders are functional, such as muscular imbalance, and that horseback riding does not cause severe lumbar disk degeneration (12). They hypothesized that constant jumping over tall fences may damage the rider’s lumbar spine, even though the horse absorbs most of the landing forces and if the rider is competent. Nachemson and Morris (17) verified the presence of high intervertebral disk pressure in the forward-flexion trunk position during show jumping. Schmidt et al. (19,20) claimed that forward movement of the trunk causes high stress moments on the lumbar spine.

Osteoporotic vertebral compression fracture is an increasing problem due to population aging (15). Postmenopausal women are at the greatest risk of fracture because of hormonal changes that can lead to osteoporosis, but perimenopausal activity, including increased bone resorption, begins as early as 40 years of age (6). In osteoporosis, low bone mass leads to bone fragility, disrupts the bone microarchitecture, and increases the risk of fracture, especially in vertebral bodies (1,2,16).

Greve and Dyson (7) reviewed factors affecting the performance of horses, riders, and their interactions, including the saddle; the rider’s experience, position, skill, and body weight; and the horse’s movement patterns. They showed that as a horse moves a rider in all directions, including up, down, forward, and backward, a skilled rider makes flexible motions, absorbing the movements of the horse; however, a less skilled rider is stiff and tense, unable to absorb the motions. In these two present cases, the combination of horseback riding and osteoporosis in amateur riders may have caused the vertebral compression fractures.

Therefore, clinicians should consider vertebral compression fracture as the source of back pain in horseback riders. Additionally, amateur riders with low BMD should be aware of the possibility of compression fracture, even when riding a horse at a walk.

The authors declare no conflicts of interest and do not have any financial disclosures. The data presented here have not been published or submitted elsewhere for publication.

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