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Head, Neck, and Spine

Head and Spinal Injuries in Equestrian Sports

Update on Epidemiology, Clinical Outcomes, and Injury Prevention

Gates, Jennifer K. BA1; Lin, Cindy Y. MD, FACSM2,3

Author Information
Current Sports Medicine Reports: January 2020 - Volume 19 - Issue 1 - p 17-23
doi: 10.1249/JSR.0000000000000674
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Abstract

Introduction

Thirty million Americans annually participate in equestrian sports (1), and the popularity of these activities continues to grow in the United States and internationally. Equestrians are at risk of serious injuries due to the high speeds involved and unpredictable nature of working with horses. Equestrians sustain more accidents per hour of sport compared with motorcycle riding, skiing, and football (2). Many equestrians engage in their sport recreationally or professionally for many years, and one in five will sustain a serious injury as a result (1). In a retrospective review of the U.S. National Trauma Data Bank, 45.2% of sports-related traumatic brain injuries (TBI) from 2003 to 2012 in adults were from equestrian sports — the highest single contributing sport to this injury type of the five sports categories evaluated (3). Fourteen percent of pediatric sports-related TBI in the same Data Bank and period were related to equestrian sports (4).

Horses are animals of prey by nature, meaning that unforeseen behaviors by horses can potentially lead to an equestrian injury. Horses weigh 900 to 1200 pounds and can deliver 1000 newtons of force from a single kick (1). When riding, the equestrian's head is approximately 8 ft to 9 ft off the ground, putting him/her at risk for head or spinal injuries when falls occur (1).

Equestrian-related activities are varied. Competition riding is often separated into disciplines including horse racing on the flat, steeplechase racing over obstacles, polo, driving, vaulting, English, and Western riding. Horse racing is when jockeys on horseback compete on a circular track, aiming to complete the race in the fastest time (see Fig. 1). The potentially high speeds associated with equestrian injuries are cited in horse racing studies, where horses can achieve speeds of up to 40 miles·h−1 (5). Out of the eight disciplines recognized by the International Federation for Equestrian Sport (FEI), three are seen in Olympic competition: dressage, show jumping, and 3-day eventing. Show jumping involves jumping a course of obstacles without knocking down the obstacle rails and in the fastest time (see Fig. 2), whereas dressage is a judged activity where riders cue horses in precise movements on the flat. Cross-country, one of the subdisciplines of 3-day eventing, consists of jumping over solid obstacles on a longer outdoor course (see Fig. 3). Western riding encompasses recreational and occupational activities, such as rodeo, cattle herding, and reining.

Figure 1
Figure 1:
Horse racing. Photo credit Getty images.
Figure 2
Figure 2:
Show jumping. Photo credit JC Markun.
Figure 3
Figure 3:
Cross-country jumping. Photo credit Ashley Neuhof.

This article focuses on published research in the past 10 years on head and spinal injuries related to equestrian sports. This article reviews the epidemiology of injuries, risk factors, clinical outcomes, and future directions on injury prevention efforts.

Injury Risk Factors

Gender distribution in equestrian injury patterns vary geographically as there are gender differences in participation in equestrian sports and horse-related occupational activities internationally. Multiple studies cite that women are more likely to be treated for injuries related to equestrian activities (6–10). Studies speculate that the higher predominance of women injured is related to the gender distribution in equestrian sports overall (1,11,12). In a survey of adults in England, eight times as many women as men report participating in equestrian activities at least once a week (13). Other studies have found men are more likely to be injured when they are the predominant gender involved in a horse-related activity. For example, individuals injured while working on a thoroughbred horse farm were more likely to be men (81.4%), with 56.8% of these being directly horse-related injuries (14).

The average age of injury for equestrians varies based on the population studied (7,8,10,15–19). Several studies cite 37 as the average age of injury (7,10,16). Injury risk was found to be highest for women ages 16 to 30 years and men older than 40 years (9). This could be influenced by the average ages at which the different genders engage in equestrian activities.

Many equestrians engage in their sport for years, and injury risk is not completely mitigated by experience. Injured equestrians are more likely to be amateurs or less experienced riders, and they also may be riding horses with less training experience (20). In an analysis of falls on race day for jockeys, apprentice or amateur jockeys had a higher likelihood of experiencing a fall (21). Experience is postulated as a protective factor for equestrians (9), and human error has been cited as contributing to equestrian injuries in over a third of accidents (22). Studies suggest that professionals are more likely than amateurs to experience severe injuries (1). This may relate to the younger age, inexperience, or difficulty of the horses they are training, their competition level, and higher hours spent in the saddle and handling horses per week (1). In one study, when injury rates were adjusted by hours spent in the saddle, experienced equestrians were injured less commonly than amateurs (22). Professional equestrians may be at an increased risk for severe injuries due to their occupational exposure load, but amateur equestrians are more likely to sustain injuries associated with lack of experience or risk-taking behaviors, such as riding without establishing the proper fundamentals necessary to cue a horse safely.

Older, more experienced horses are believed to be safer to ride. As horses age, their predictability and rideability typically increases and they tend to have a calmer disposition, making them less likely to make unpredictable movements that predispose an equestrian's fall. The average horse age when equestrians were injured in one study was found to be 7 (23), suggesting that younger horses may be involved in more falls than older, experienced mounts.

There are limited data on environmental factors contributing to equestrian injuries. One survey found that 40% of injured equestrians cited environmental factors as contributing to injury (19). A literature review found that falls were most likely to occur during warm weather (24). This also could be related to higher participation in equestrian activities when weather is favorable.

Equestrian injuries are most likely to occur when a rider falls, or unintentionally dismounts a horse, compared with other mechanisms. Falling off a horse is cited as the leading cause of injury in multiple studies (6,11,16,22,25–27), and a literature review cited injuries as most commonly occurring from a fall (24). Injuries also are more severe when the rider falls versus other mechanisms of injury (27). Unexpected horse behaviors that may be associated with falls include rearing, bucking, bolting, and spooking. Horse falls are a major risk factor for equestrian falls (28). Catastrophic musculoskeletal injury or sudden death of a horse while flat racing was reported as the most common cause of jockey falls in both Thoroughbred and Quarter Horse races (28). Equestrians and horse handlers also are at risk for injury if a horse swings their head or another part of their body, resulting in a blow to the equestrian's body. For this reason, helmets are recommended not only while riding but also when handling horses on the ground.

Overall Injury Patterns

The most commonly reported injury from equestrian sports varies by source, but there has been a reported shift in recent years from a predominance of head injuries to an increased number of extremity fractures (1). This is believed to be related to the increased use of helmets in equestrian sports. Head injuries occur in 23% to 27% of equestrians presenting to the emergency room (16,17,26,29), although extremity fractures were present in a higher percentage of cases, in approximately 30% of patients seen in hospitals for equestrian-related accidents (16,17,26). Lacerations and soft tissue contusions were present in 58% of pediatric patients seen after an equestrian fall, and it is postulated that minor injuries, such as these, occur at higher rates than severe injuries among equestrians (26). Equestrians injured while mounted are more likely to have chest or lower extremity injuries whereas unmounted equestrians have higher rates of face and abdomen injuries (16). One study in Australia found that in pediatric patients, unmounted injuries, meaning the equestrian was on the ground, were twice as likely as mounted injuries, to require intensive care or surgery, and eight times more likely to sustain a severe head injury (30). Stable staff, grooms, and horse trainers also can be injured while unmounted and handling horses on the ground. Occupational riding injuries account for 8% of mounted horse-related trauma presenting to a level 1 trauma center, while the majority of injuries occur in recreational settings (16).

Similar to injuries overall, head injuries also are more likely to occur when an equestrian falls from a horse. A retrospective study found that equestrians who sustained a TBI were most likely to have done so by striking the ground (96.4%) or striking other objects (3.6%), both of which can occur from a fall from a horse (31). Spinal fractures or spinal cord injuries (SCI) also can occur from a fall from a horse.

Head Injury

Head injury rates vary based on the injured equestrian population studied, with rates ranging from 11% to 48% (2,9,10,15,16,18,22,25,27). Multiple studies cite that approximately one quarter of equestrians seen in an emergency room after a fall have an associated head injury (9,10,16,22). TBI were reported in 16.2% of all patients from a retrospective cohort study on equestrian-related injuries (31). Mild TBI have been cited as the most common head injury for equestrians (3,4). These head injuries are more frequently seen in adults, while children are more likely to sustain extremity fractures (32). However, children are at a higher risk for a severe TBI due to their greater head-to-body size ratio and thinner skull bones (33), highlighting the necessity of children wearing helmets and using proper safety precautions when mounted or unmounted around horses. Skull fractures are observed at various rates among equestrians injured with and without helmets (13,18,31,32).

Focal neurological deficits, epidural hematoma, and amnesia were more likely among pediatric patients with horseback riding-related injuries compared with pediatric TBI patients injured during soccer or cycling (25). One study identified TBI from equestrian accidents ranging from small punctate hemorrhages to large extra-axial hematomas requiring surgical intervention (34). TBI vary in type and severity and reported rates also may depend on the brain imaging modality and acquisition time in relation to the injury.

Helmets are believed to reduce head injury severity but have not been shown to reduce incidence of TBI, specifically concussions. Equestrians not wearing a helmet are more likely to sustain intracranial hemorrhage in an accident (34,35). Lack of helmet use also has been correlated with an increased injury severity overall, higher Injury Severity Scores and increased odds of loss of consciousness (25,35).

Concussions are the most common TBI presentation in equestrians and can be caused by direct blows to the head or whiplash force transmitted to the brain (36). The signs and symptoms of a concussion may vary, with loss of consciousness being present in only some cases, and the most common symptoms being headache, dizziness, difficulty concentrating, and/or confusion. Most concussion symptoms resolve within a few weeks, but their presentation and symptomatology can vary greatly. Athletes who are suspected of a TBI should be removed from practice or competition and have medical evaluation before they are given clearance to return to their sport as recommended by the Berlin Consensus Statement on Concussion in Sport (37–39).

Spinal Injury

Injuries to the vertebral column account for half of all trunk injuries among equestrians, and trunk injuries are less frequent in equestrians compared with extremity injuries (27). Spinal injuries are reported to be present in 2.4% to 14% of all equestrian injuries and most commonly involve the lumbar or thoracic spine (9,12,18,40). Of 50 cases of riding-related spinal fractures, 51% were lumbar, 32% were thoracic, and 17% were in the cervical spine (41).

A retrospective study conducted on the U.S. National Electronic Surveillance System from 2002 to 2004 found 123 incidences of spinal injuries with and without neurological deficits among equestrians presenting to emergency rooms after a riding-related injury (18). SCI are relatively uncommon in equestrians but can have significant neurological consequences. A retrospective study of the U.S. National SCI Statistical Center database found that the most common levels of preserved neurologic function after SCI were C4-C6, T12, and L1. SCI from riding accidents most commonly resulted in incomplete tetraplegia (41%) followed by complete paraplegia (24%), incomplete paraplegia (19.8%), and complete tetraplegia was a less common occurrence (8.3%) (42). SCI in equestrians are more likely to occur at a higher mean age of injury of 37.8 years than for SCI related to diving, motorcycle riding, football, and gymnastics (42). There are limited data on mortality rates for spinal injuries among equestrians. Spinal cord trauma is a predictive factor for receiving inpatient rehabilitation (18).

Injury Prevention

Given the potential severity of TBI or SCI related to equestrian activities, more attention needs to be paid toward identifying injury risk factors and injury prevention efforts. Injury prevention efforts can range from education to increasing appropriate use of protective equipment and policy changes.

Helmets

Helmets are postulated to reduce the severity of impact and the resulting head injury from a fall, and studies suggest that they reduce the likelihood of skull fractures (43). The FEI requires that athletes wear properly fastened protective helmets when riding on the showgrounds at international events (44). There are policies that vary for whether helmets are mandatory when riding to and from the horse stables or other places on the competition premises (39,41,45). The United States Equestrian Federation (USEF) has required helmet usage in sanctioned jumping competitions since 1964 (46). A rule change in 2011 by the United States Eventing Association (USEA)/USEF, requires that equestrians always wear an American Society for Testing Materials (ASTM)/Safety Equipment Institute (SEI)-certified helmet while mounted on competition grounds (47). In addition, the FEI will implement a rule in 2021 requiring that equestrians of all disciplines must wear a helmet at all times while mounted on the show grounds (48).

Current equestrian helmet design and certification criteria are primarily based on linear acceleration impact testing. Multiple certification methods exist internationally, and the FEI recommends helmets that are tested to British Standard Product Approval Specification (PAS) 015, European Community (CE) Standard, ASTM F1163, American Snell Guidelines, or Australian ABBHS2012 and AS/NZ 3838 standards (49). ASTM-certified helmets must have less than 300 g of acceleration force (50). CE standard involves testing the energy absorption of helmets when there is a perpendicular impact (51). However, equestrian falls or kicks to the head may involve rotational acceleration forces (51,52). Future helmets should employ new technologies that aim to reduce brain injuries from these forces. A technology called the Multi-Directional Impact System reduces some rotational forces on the brain, resulting in lower impact when studied with finite element analysis (51), and is available for equestrian helmets. However, there is a need for improved, innovative equestrian helmet technologies that further mitigate impact and rotational acceleration forces on the brain.

Equestrian helmet use is only mandated in the United States by several states and by municipal government ordinances. New York was the first state to adopt laws around helmet use (47) and requires children younger than 14 years to wear helmets while riding on public roads and highways, and Florida's law requires all riders younger than 16 years to wear helmets in a public setting (53). Norco, California also has a law mandating helmet use for those riding younger than 18 years (54), and New Jersey has a law requiring ASTM-certified helmet use when horseback riding on state owned lands (55). These regulations vary and in some cases require a fine if individuals are found not wearing a helmet (56). There is currently no uniform European Union law on helmet use, but the United Kingdom, Germany, and other countries have laws related to helmet use in children (56). In addition to increasing certified helmet use and improving certification and testing standards, correct helmet size, fit, and appropriate chin strap usage are critical.

Safety Vests

Safety vests are intended to protect an equestrian's torso by absorbing impact in the event of a fall. Currently, there is a low level of safety vest usage among the general equestrian population. A survey of injured equestrians found that only 14% reported wearing safety vests at the time of injury (57).

Some studies found no association between safety vest use and a decrease in torso injuries, whereas another indicated that safety vest use specifically in cross-country equestrians is associated with a decrease in reported injury rates and a lower incident severity (27,58–60). In an analysis of FEI data from 2015 to 2017 of falls in international eventing competitions, riders using an air jacket had 1.7 times (95% CI 1.14–2.64) increased odds of sustaining a serious or fatal injury in a fall compared with riders not wearing an air jacket (61). Future research is needed to clarify these injury patterns and the characteristics of riders who wear safety vests.

Safety vests to date have not been shown to significantly decrease the risk or severeity of spinal injuries (62). The neck is not protected by safety vests, leaving the cervical spine at risk for injuries. Injuries to the cervical spine can be associated with SCI (62). Since current vests have limited evidence to date for severe injury risk reduction, cost may influence an equestrian's decision to purchase and wear safety vests.

Innovation of safety vests that also protect the cervical spine from injury would benefit the equestrian community. Inflatable collars have been suggested as a mechanism to reduce these injuries (63). A new trend in the equestrian community is air vests, which inflate in the incidence of impact or a fall (63). These vests also include cervical collars which inflate upon impact to reduce neck hyperextension. Currently, no published studies have indicated whether airbag collars reduce the incidence of cervical spinal cord trauma.

Policy

Policies regarding equestrian and jockey TBI acute management and return to sport guidelines vary based on the sport's governing organization and for some racing and equestrian sports and governing bodies, policies do not yet exist. In the event of a fall or accident during competition, equestrians and jockeys should be evaluated by a qualified medical professional prior to competing again (64). Sports medicine physicians covering equestrian and racing events should have a low clinical threshold for referral to emergency room or trauma center for further evaluation if an intracranial process or spinal injury is suspected. USEF and FEI both require that individuals suspected of TBI must be removed from competition for evaluation by a qualified medical professional and an incident report form completed (65). There is currently no standardized, national concussion return to ride protocol for jockeys in U.S. horse racing, although individual states and tracks may have their own protocols. This is an area being researched by several groups including at University of Kentucky (66).

Both USEF and FEI require registered sporting events to have an Emergency Accident Preparedness Plan (1). The FEI has a doctor's pack available, which details guidelines on emergency medical personnel and injury response. FEI competitions are required to have personnel trained in emergency medical care over the duration of the competition, and a medical coverage plan that details procedures, ambulance coverage, and local hospitals with emergency trauma services. The FEI also requires that there is a dedicated medical provider, a quiet area onsite for evaluation of athletes with the Sport Concussion Assessment Tool, and a plan for acute stabilization of athletes with neurological injuries (65).

Discussion

Further research and injury surveillance would be beneficial to establish the root cause of equestrian accidents that result in severe TBI or SCI given their associated morbidity and mortality. Biomechnical modeling can be challenging given that equestrian accident scenarios can vary significantly (63). Root cause analysis after critical incidents in competition or races also could help researchers and policy makers to understand the specific mechanisms and contributing risk factors. There are limited published data on injury risk factors such as horse behavior, horse characteristics, environmental factors, and an equestrian's characteristics as related to injury outcomes.

Additionally, current equestrian helmets reduce the risk of skull fractures without providing adequate protection against concussions. Most helmets are composed of a hard plastic outer covering and inner foam layer, designed to absorb impact in the event of a fall. Equestrians are instructed to replace their helmets after any fall, as the foam liner will not protect against subsequent impacts. One recent study suggests that the greater stiffness of the outer shell may result in certain helmets not being able to sufficiently diffuse forces that can cause concussions (43). Future equestrian helmets could consider advanced technologies, such as those seen in recent football helmets, which aim to reduce rotational acceleration forces to the brain.

Legislation mandating use of certified helmets in all equestrian sporting events while mounted should be strengthened by United States and international governing bodies. Given the unpredictability and inherent dangers of mounting or handling horses in any capacity, increasing helmet use, despite the limitations of current helmet designs, could mitigate head injury risk.

Improved reporting and monitoring mechanisms for equestrian and jockey injuries would aid in better analysis of risk factors and developing injury prevention policies. Major injuries are reported to governing bodies such as the USEF at national competitions and the FEI for international sporting events (11); however, a majority of injuries occur recreationally and outside sanctioned competitions and are underreported. In 2012, the British Horseracing Authority convened experts on equestrian injuries from the four countries in Europe where horse racing is most prevalent. In this meeting, they concluded that greater transparency and injury recording efforts are needed in order to improve safety recommendations and outcomes (67).

Given that equestrians who sustain multiple falls are at a higher risk for neurological deficits (12), equestrian education on concussions is warranted. Currently, 40% of equestrians report never receiving education on concussions (45), with 15% garnering information from their trainers. Educating both the equestrians themselves as well as their trainers/coaches could help prevent injuries and ensure an informed return to sport after a concussive injury. Campaigns around concussion awareness, such as Heads Up! can improve rider awareness of helmet safety. Equestrian training programs that focus on basic skills such as improving appropriate use of rein pressure, leg stability, the rider's center of balance, and general horse safety have been correlated with improved equestrian safety and could help mitigate injury risk (68). Programs, such as Landsafe and Saddle Up Safely, aim to educate riders on these best practices (69,70).

Rotational falls, in which a horse's front legs or chest impacts a solid fence and results in the horse's body somersaulting over with the fence acting as a pivot point, can result in significant injuries to both the horse and the equestrian. Improvements in jump course design and safety could help reduce these risks. One example of this is frangible pin technology, which allows jump obstacles to collapse in the event of a horse hitting the obstacle (see Fig. 4). Frangible technology works to allow the jump to collapse if the horse hits the fence at a specific vertical angle (71). However, certain impact types may not activate the safety mechanism of frangible pin technology. Other obstacles on jump courses have been identified to be potentially associated with higher injury risk, such as those that are round, have a square spread, or are on downhill terrain (72). It has been suggested that solid jumps themselves are the primary risk factor for cross-country eventing injuries to both horses and equestrian, and future technologies should aim to mitigate the risk factors associated with solid obstacles (73) and take into consideration the visual judgment capabilities of the horse.

Figure 4
Figure 4:
MIM clip frangible technology in a jump obstacle. Photo credit Ashley Neuhof.

In horse racing, efforts to prevent the most common equine catastrophic acute musculoskeletal injuries associated with horse falls during racing, namely, carpal, metacarpal, and fetlock injuries, are critical in reducing jockey falls. Jockey riders were significantly more likely to fall or become injured when they rode a horse that died in a race due to a catastrophic musculoskeletal injury (28).

Educational programs for both equestrians and trainers/instructors around head and spinal injury prevention and acute management also could improve sports safety. This training could include aspects such as how to properly fit a helmet, to obtain a new helmet after impact, and how to respond when an equestrian is found down with a suspected head or spinal injury.

Conclusions

In conclusion, TBIs are among the most common injuries in equestrians. More can be done to increase certified helmet use by equestrians and to improve helmet design to reduce the risk of TBI. Currently, there is no safety vest that prevents spinal injuries. Further studies are needed to better understand injury mechanisms and risk factors for catastrophic falls, such as rotational falls or horse falls, that can lead to equestrian or jockey falls and how to prevent these critical incidents. Educational efforts for riders and trainers to improve acute response to potential TBI and spinal injuries in and out of competition may constitute part of a comprehensive approach to improving safety in equestrian sports.

The authors would like to acknowledge Michael Turner, MB BS, FFSEM (UK), Hon Associate Professor University College London, for his informative comments on the article.

The authors declare no conflict of interest and do not have any financial disclosures.

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