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Extremity and Joint Conditions/Special Communications

Medicine in the Sport of Horse Racing

Ryan, Kelly D. DO, CAQSM1,2; Brodine, Joseph MPH, MD1,3; Pothast, Jason MD, CAQSM2,4; McGoldrick, Adrian MB, MICGP, FFSEM5

Author Information
Current Sports Medicine Reports: September 2020 - Volume 19 - Issue 9 - p 373-379
doi: 10.1249/JSR.0000000000000750
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Abstract

Horse racing is among the most popular sports in the nation with attendance figures exceeding all other professional and collegiate sports in the United States and an annual revenue of more than one billion dollars for prize purses. For centuries, audiences have been drawn to the spectacle of a human rider atop their animal partner racing at highway speeds (1). The average jockey weighs less than 120 lb yet they must control a thoroughbred horse 10 times their weight that may act unpredictably whether at rest or full gallop resulting in falls, kicks, or even biting injuries (2). Despite the risks, jockeys do not have access to the same quality of medical care that is standard in similarly profitable sports organizations. Compared with its international peers, the United States horse racing industry does not uniformly observe safety protocols or possess medical oversight infrastructure in the fashion of jurisdictions administered by the Irish Turf Club and the British Horseracing Authority.

Central to the vision of improved jockey medicine in the United States is the education of sports medicine practitioners to prepare them for the particular care needs of their athlete patients. Beyond the mental and physical demands of training and performance endured by any professional athlete, jockeys are confronted with health challenges unique to their sport. The weight restricted-nature of horseracing (3) is an added challenge particularly without sacrificing strength, and the mechanisms of injury typically involve a greater degree of momentum. In this review of the literature, we aim to educate sports medicine physicians regarding the underlying causes of injuries, describe injury management, and make recommendations for appropriate preventive strategies.

Introduction to the Athlete

Jockeys in professional horse racing are predominantly men, a key difference from other recreational equestrian activities (4). Professional jockeys have a wider age range than athletes in other professional sports; apprentice jockeys are as young as 16 years, while many successful jockeys retire in their late 50s. Many jockeys who race in the United States emigrated from Central America as well as the Caribbean and must be eligible to work in the United States to receive their riding license. Jockeys may have attended racing schools where they developed racing skills while learning general grooming and care of the animal; however, it is not a requirement to race professionally.

Horse racing is unique among equestrian sports in its strict weight requirements. A jockey's average weight in the United States is between 112 and 119 lbs with a typical height between 4 ft 10 inches and 5 ft 6 inches (5). A jockey new to the sport is referred to as an “apprentice,” and they are allowed to weigh less than the other jockeys, thus conferring an advantage to compensate for their relative inexperience.

On a typical day, jockeys rise before dawn to partake in a full morning of riding at the track. They often “breeze” horses early in the morning to prepare for a future race, running variable distances based on the horse's training schedule. The athletes may then practice weight lifting or aerobic exercise routines or attempt weight-cutting measures to maintain racing weight. Working jockeys typically participate in one to twelve races in a single day. Some may race 7 d·wk−1, and motivated jockeys may travel to several tracks within a single race day. The long hours of traveling and riding may preclude opportunities for adequate sleep, which can result in decreased reaction time and concentration during performance.

Jockeys are independent contractors who have agents to negotiate with trainers and owners on their behalf to obtain permission to ride their horses in a race. Superior riders can pair with better horses, which in turn allows jockeys to compete for more valuable purses. Apprentice jockeys who are newer to the profession may breeze multiple horses without pay for successive mornings in the hopes of being selected for future races. On race days, Maryland riders are paid a base fee of approximately US $75 to US $100 per race for participation with the opportunity to enjoy a percentage of the purse based on their finishing placement. In Maryland that is approximately 6% for first place. While novice riders can work until exhaustion for weeks with minimal pay, established riders may earn more than one million dollars annually. The average salary of a jockey is not easily accessible, as the numbers reported are for the winnings of the horses, not the individual jockeys.

Training and Preparation

The Demands of Riding

With each race, jockeys must tolerate between 45 s and 85 s of intense mechanical and physiologic stress. As the horse's speed increases, riders adapt their stance and position to remain atop the horse. At high speeds, jockeys enter a “suspension phase” when they are no longer seated on the saddle to “accommodate vertical accelerations of the horse's trunk” (6). These motions demand enduring strength of riders' gluteal muscles, quadriceps, and hamstrings for stabilization as well as the trapezius and core muscles to maintain a hyperextended posture of the head and neck.

In addition to muscle strengthening, some authors have studied aerobic fitness requirements for optimal performance among jockeys. Cullen et al. (7) recorded peak heart rates of approximately 190 bpm during flat racing which led to the conclusion that jockeys should engage in aerobic and strength training in addition to horse riding. This recommendation was supported by authors who found that a jockey riding at a canter gait (between a trot and a gallop) expends approximately 7.7 metabolic equivalents of a task, which is approximately the same energy demands of bicycling at 19 km·h−1 to 22 km·h−1. To develop adequate cardiovascular reserve, athletes must engage in exercises that will “match or exceed” the physiologic demands of racing (8). In a study by the National Athletic Health Institute, jockeys were shown to be in better physical condition on average than professional football, baseball, basketball, and hockey players (9).

Unlike most other sports, horse racing has no defined season. Athletes ride year-round and are challenged by adverse weather conditions and limited time to heal and rehabilitate from injury. In a study of injury history by Jeon et al. (10), most of the jockeys surveyed were “unsatisfied with the length of their recovery period and felt that their injuries negatively affected future competitions.”

Mental Health

Among jockeys, performance pressure is compounded by the reflexive adrenergic response to mounting a large, unpredictable animal at high speeds. Contrasted against the adrenaline surge during racing, periods of recovery after injury are marked by physical pain, loss of income, and missed opportunities to participate in high-profile contests. The emotional and physical demands of the sport predispose jockeys to a greater risk of depression compared with the general population (11,12). Convalescing athletes with years of accumulated injuries are susceptible to substance abuse including alcohol and opioids (13). This population of athletes is particularly vulnerable: without the protections of a contract or labor union, jockeys are ad hoc laborers who are susceptible to dismissal or blacklisting if they self-report abuse. Uninjured jockeys are not immune to substance abuse either; the narrow margin of acceptable racing weight has compelled many athletes to abuse diuretics or amphetamines. Other efforts to lose weight include starvation diets and bulimia, which predispose jockeys to long-term eating disorders (11,14). Though it is challenging to quantify the disease burden wrought by behavioral health issues, Losty et al. (11) estimated that one in every two professional jockeys were classified as meeting the established threshold score for depression and perceived stress.

Weight Management

Horse racing requires a jockey to be of a certain weight, determined by each track and the conditions of the race. The total amount of weight a horse carries in a race is dependent on the horse's age, sex, past performances, and type of race. The total mass the horse carries in addition to the jockey includes the helmet, flak jacket, clothes, and saddle, which typically ranges from 115 lbs to 126 lbs. To meet weight requirements, jockeys need to be at least 3 lbs to 4 lbs under this goal weight, which can be difficult to achieve and maintain.

Jockeys may attempt a variety of methods to “cut weight” on race days, including fasting, induced vomiting, calorie restriction, or dehydration through the use of saunas and sweat suits (15). In one study, the jockeys participating in the research reported a 2 kilogram weight loss 24 h to 48 h before race day, most often using saunas, exercise, and calorie restriction. Their mean daily caloric energy intake was low: a large number of the jockeys failed to meet the daily requirements for micronutrients and carbohydrates for athletes (16). A 2016 study demonstrated a measured average “in race” heart rate of 167 ± 12 bpm and that jockeys operated at 90% HRmax during races. The authors noted that these types of high intensity efforts in combination with fluid and caloric restriction occur at least weekly during a competitive season (17). Wilson et al. (15) described that this state of chronic restriction can compromise muscle and liver glycogen stores as well as circulating blood glucose concentration, which are essential for the healthy regulation of standard bodily functions. In addition, other research has found that while dehydration may not impair short-term cognitive performance, its impact on long-term cognitive function remains unclear and warrants further investigation (15,16).

Bone Health

Relative Energy Deficiency in Sport (RED-S) is of real concern for many practitioners caring for jockeys. The aforementioned disordered eating in combination with a demanding exercise regimen, puts many jockeys at potential significant risk for RED-S. Having a year-round energy availability mismatch can contribute to a variety of physiological adaptations, of which include a reduction of testosterone in males, possibly impaired judgment, decreased performance, depression, irritability, decreased coordination, altered immune system functioning, and decreased bone mineral density (18).

Jockeys have lower bone density than matched controls (19–22) as well as elevated rates of bone loss associated with disrupted hormonal activity (22). Male jockeys also tend to have lower bone density and resting lower metabolic rates than their female counterparts when compared with sex-matched controls, which suggests that male jockeys’ health may be more comprised than their female counterparts (23).

Low bone mass is particularly concerning in a sport where jockeys experience significant traumatic falls that may lead to fracture. One study attempted to alter this trend by supplementing jockeys with 800 mg of calcium and 400 IU of vitamin D. After 6 months, there were promising signs of positive alterations to bone metabolism but longer studies need to be carried out to see if this positive trend is correlated to a longer term bone density improvement (24).

The long-term impacts of chronically trying to make weight are still yet to be determined. Cullen et al. (3) evaluated a group of retired jockeys between the ages of 50 and 70 years. The author found no significant difference in bone health, kidney nor liver function compared to age-matched controls. However, it was hypothesized that these retired jockeys may not have undergone some of the more extreme weight cutting techniques used in today's racing.

Wilson et al. (25) compared bone density and metabolic characteristics between a group of senior and apprentice jockeys. Despite a clear difference in years of riding, there were no statistical differences in bone mineral density or resting metabolic rates. The authors suggest that low bone mineral density in jockeys may not be necessarily due to low energy availability alone, but rather from a lack of osteogenic stimulus associated with the low impact of riding. While larger studies need to be completed, this is an interesting alternative point of view toward the reasoning behind chronically low bone mineral density in jockeys. There could be potential for a shift in these metabolic trends if one were to follow the aforementioned case study with an improved dietary plan, in combination with higher impact exercise to stimulate bone density growth.

Jockey Injuries: From Stable to Finish Line

Compared with most professional sports, the range, severity, and frequency of injury is higher among jockeys. An analysis of European flat racing described 2.7 to 4.4 falls per 100 rides with 40% to 59% of these falls resulting in injury (26). The majority of published injury data describe falls, but a recent study by Mackinnon describes a common sequela: the most prevalent health outcome of retired jockeys was osteoarthritis occurring at a rate of 7.5 times higher than in reference population (12). In an analysis of such fall injuries, jockey falls during flat racing were caused by horse stumbling (25.5%), horse injury (20.1%), jockey error (19.1%), involvement in an accident (12.2%), bad behavior of the horse (11.2%), and other unspecified causes (0.7%) (27). In a study of British horse racing between 1991 and 2005, head injuries, back injuries, and shoulder injuries accounted for the highest incidence for career ending injuries (2). After a review of claims made for worker’s compensation in Australia between 2002 and 2009, falls occurring during the race had the highest average claim cost (28).

Injury can occur at any phase in the race sequence. Just prior to the race, horses, trainers, and jockeys are in an enclosed area called a paddock where the horses are settled while the jockeys mount them. Jockeys are at risk of injuries from horse kicks from the moment they come in close proximity to the horse until after they have dismounted and moved out of reach (1). Horse kick strength has been estimated at 400 joules (J), which is four-fold the test impact load of approximately 80 J to 100 J for most equestrian helmet standards. The force of a horse's kick can easily cause a skull fracture, intracranial hemorrhage or life-threatening internal injuries (29).

Once saddled in the paddock, the competitors are led to a “post parade” where the racehorses are paired up with a “pony” that serves as a calming companion for the thoroughbred racehorse, a breed known for its excitable temperament. During the post parade, members of the public will place their bets while riders warm up their horses for the race. A pony accompaniment is not practiced in all countries; there is a higher incidence of prerace injuries in Australia where ponies are not utilized as they are for their U.S. counterparts (27) but further research would be necessary to understand the significance of this injury prevention strategy.

After the post parade and warm-up, horses are then led into the starting gate consisting of small metal stalls where an attendant directs the horse into the gate. Attendants take hold of the horse to keep them calm up until the gate flies open at the start of the race. According to Waller et al., injuries of the extremities commonly occur in the starting gate. Lower limb injuries occur as a result of the jockey being crushed into the walls; upper limb injuries occur when a jockey is flipped and pinned by the horse (30). Industry efforts to improve the safety of the jockey and horse while in the starting gate include decreasing the startling effect of the starting bell and heavily padding the sides of the stall.

At the sound of the bell, the horse breaks from the gate and the jockey must stay atop the horse by getting into a semisquat position by balancing on stirrups. Should the horse stop suddenly, the jockey is thrown forward over its neck into the rail or onto the track and into the path of other horses (1). Around the final turn, speeds increase and jockeys begin to “go all out” by lowering their body position and maintaining a low squat position while attempting to decrease excessive movement. Fall from a height at a high rate of speed may lead to a wide variety of injuries, including spine injuries, upper and lower extremity fractures and dislocations, and joint injuries (31). Many authors have described that soft tissue injury is more common than bony trauma or organ damage; the majority of falls result in muscle contusions, ligament sprains, and ligament strains (1,32). Fractures are less common but can result in greater severity of injury (9,27,32,33). In the National Jockey Injury study conducted in 1990, 60% of the 706 professional jockeys surveyed reported a fracture during their career and on average were seen three times annually for injuries related to their occupation. While specific fractures are not typically documented in the literature, bony fractures often tend to be comminuted and atypical due to the nature of the trauma. The third most common type of injury is concussions. In addition to falls, riders can be thrown from the horse resulting in multiple injuries (30), most commonly to the lower limbs, head, and shoulders, upper limbs, and back (27,33,34).

In the United States, veterinarian and human ambulances follow the riders during the race. It is imperative that medical staff be able to get to injured riders immediately within seconds to the potential life-threatening injuries that can occur. Although the final stretch and finish line are otherwise free of obstacles, the speed and close proximity of the horses and final risk-taking tactics of the jockeys increase the impact of throws and other undesired dismounts (30).

Medical coverage, rules, regulations, and protocols as well as health and disability insurance varies state to state and track to track. Some organizations provide medical coverage, whereas other states it is recommended jockeys purchase their own, although not always required and some riders are without insurance. Tracks have some disability and catastrophic insurance, but this policy also changes among states. In the State of Maryland, the tracks have a Sports Medicine contract for race day coverage (Primary Care Sports Medicine Physician) and riders have injury coverage under Worker's Compensation if they endure an injury associated with riding.

Responding to Injury: Specific Protocols

Trauma

Falling from a height of more than 6 ft at high speed may lead to significant injury, thus it is imperative for an established trauma protocol to direct evaluation and triage. According to the United States Centers for Disease Control and Prevention's triage tree (35) motorcycle accidents going 20 mph should be considered for a trauma consult by onsite emergency medical service. Furthermore, the Canadian Computed Tomography (CT) Head Rules state that a fall greater than 3 ft is considered a dangerous mechanism of action with a recommendation for head CT to rule out intracranial trauma (36). With most injuries sustained in the home stretch as jockeys travel well above 20 mph, all falls should be considered for a trauma consult.

Despite the potential severity of trauma, there is a greater need for coordinated response rather than advanced medical training of rescue personnel. The authors of the OPALS study concluded that the implementation of full prehospital advanced life support by trained paramedics was not associated with lower mortality rates relative to basic life support measures for patients with major trauma. For patients with suspected head injuries and a Glasgow Coma Scale score of less than 9, mortality was greater during the advanced life-support phase of the study than during the basic life-support phase (37). Thus, the critical intervention for severe trauma is a well-developed communication plan to notify, direct, and communicate with local emergency medical services to transport the rider to a trauma center expeditiously (37).

Concussion and the “Return to Ride” Protocol

In horse racing, concussion is the most common head injury endured by jockeys. In a recent study by Connor et al. (38), 126 (91%) of 139 head injuries reported by the Irish turf club between 2015 and 2018 were concussions. O'Connor et al. (34) noted that between the years of 2011 and 2015, there were an average of 0.2 concussions per 1000 rides, 28.6 concussions per 1000 falls, and 10.8 concussions per 1000 meetings. Despite the high incidence, there is a lack of uniformity among the responses practiced at U.S. racetracks perhaps attributable to the difficulty identifying cases of concussion.

Among sports injuries, concussions are some of the easiest to suspect, but most difficult to diagnose. Concussion is often characterized by nonspecific symptoms, including dizziness, headache, fatigue, and cognitive changes — symptoms that could be mistakenly attributed to the injuries sustained during rigorous physical training and weight reduction commonly practiced by the athletes. After a fall, jockeys may have difficulty focusing their attention, which may limit their ability to aid providers in diagnosing the traumatic brain injury.

Ideally, a fallen rider should be evaluated for life-threatening injuries. Once deemed stable, a physician trained in recognizing concussions using a symptom checklist should evaluate them. The athlete should be moved to a quiet area to administer concussion testing using the Sport Concussion Assessment Tool, 5th edition which includes a brief neurological examination, symptoms checklist, brief cognitive assessment (Standardized Assessment of Concussion), and a balance assessment (39). The primary endpoint for sideline assessment is to determine the probability that an athlete sustained a concussion (40). Vestibular and ocular systems are important for jockeys and often affected by concussion. Performing Vestibular Ocular Motor Screening has been helpful in recognizing these deficits and further establishing a diagnosis (41).

The Return to Play protocol is a well-accepted method of returning concussed athletes safely back to sport in a stepwise fashion. We believe it is important to adapt this protocol to the unique needs of jockeys to properly evaluate their fitness to race and protect them during recovery. Horses are prey animals by nature, prone to startling easily and throwing riders even at slow speeds risking reinjury for the concussed athlete. We suggest a “Return to Ride” protocol that delays the resumption of horse-riding to the latter phase of recovery from both concussion and soft tissue injury. Mechanical horses are useful tools that simulate riding at variable speeds and recreate the conditions of race days. The proposed “Return to Ride” protocol directs concussed athletes to utilize simulated riding apparatus so that physicians can evaluate jockey's balance and coordination as they hold their stance on the machine. Providers also can assess riders' autonomic regulation of metabolic demand by requiring athletes to demonstrate tolerance to certain heart rate parameters described by Leddy et al. (42). This protocol may prove useful for riders without concussion but suffering from soft tissue injury who must demonstrate adequate strength, pain control, and activity tolerance prior to racing (see proposed Return to Ride, Fig.).

Figure 1
Figure 1:
Return to ride communication tool.

Injury Prevention

Optimal injury prevention strategies should consider environmental, equine, human, and systems factors. The predominant environmental factor is the track itself; and in flat horse racing, there are multiple types of track surfaces. All-weather tracks are constructed of a sand/fiber/binder combination that resists freezing (30). Some races occur on dirt tracks, while others take place on turf or grass. Dirt and turf surfaces are significantly affected by weather, subsequently reducing the safety of the horse and rider. Track surface affects race completion times and may be scored as “fast,” “good,” “sloppy,” “slow,” or “muddy.” Surface conditions are often reported along with injuries so that track conditions may be addressed to mitigate incidence of injury. While policies governing track conditions are not uniform, the racing industry has sought to enhance safety through environmental interventions such as modified railings that break away more easily and modified the gates with increased padding and space (9).

Human and equine factors represent additional opportunities for improved safety policy. Hitchens et al. (43) reported that risk factors for falls in flat racing included inexperienced riders (apprentice or amateur jockeys), inexperienced or younger, and shorter race distance. In this first study to comprehensively investigate the effect of jockey experience on falls among thoroughbred racing jockeys, Hitchens et al. (43) proposed that the by restricting apprentice jockeys from riding inexperienced horses, injuries may be decreased. In an effort to better identify barriers of injury reporting for United States jockeys, Hitchens et al. (44) proposed several opportunities for injury prevention (see Table).

Table - The Haddon matrix and example countermeasures applied to the reduction of falls and injuries to jockeys in horse racing.
Jockey Horse Race Conditions Rules and Regulations
Prefall or injury Prevent or reduce Education and training; Physical assessments; Increase jockey minimum weights Education and training; Safety equipment; Preracehorse examinations Produce safe track conditions in which to race (e.g., track surface); Train starting gate crew Cancel or postpone races if track surface is deemed to be unsafe; monitoring of alcohol/drug use for both jockeys and horses; weather protocols; outriders
During the fall or injury event
Minimize, control, and protect
Fall training; Strength and conditioning; Helmet use Ensure equipment on horse is maintained Starting gate padding; Safety rails Minimum helmet and vest standards
Postfall or injury Rapid response, treatment and rehabilitation Understanding of protocols (e.g., lying still in case of back injury); Easy access to services Veterinarian or other to attend to horse; Veterinarian to monitor horse post fall if necessary Ambulance and veterinarian follows race field from mounting to dismounting Minimum 2 ambulances on course; Reporting to insurance agency; EMS skill level (EMT vs Paramedic, BLS vs ACLS vs ATLS)
ACLS, advanced cardiovascular life support; BLS, basic life support; EMS, emergency medical service; EMT, emergency medical technician.

Helmet Design

Equestrian helmets, similar to bicycle helmets, are designed to withstand a single impact. The outer shell of a helmet is fabricated from plastic — usually acrylonitrile butadiene styrene or a fiber reinforced plastic composite — and rests upon an energy-absorbing liner made from expanded polystyrene or expanded polypropylene that loses its integrity following an impact (38). Helmets are designed to attenuate energy on impact by deformation of the inner lining of the helmet. A recent study by Connor et al. (38) reported that 189 riders sustained an injury in conjunction with a helmet return scheme and that 139 (70%) had an associated head injury. A total of 75 (54%) of the head injury cases had an associated damaged helmet and 64 (46%) of helmets showed no evidence of damage. This study reflects the need for improvement to helmet design and testing; currently there is no helmet that can adequately absorb the momentum from a fall to reliably prevent concussion. It also is important to educate riders to replace their helmets after impact. Riders also should understand proper storage of helmets; helmets should not be exposed to frequent temperature changes and athletes should avoid unnecessary impact such as tossing their helmet into the back of a car trunk or into their locker.

Conclusion

Until the body of science behind horse racing medicine matures, the basis for practice will continue to derive primarily from expert opinion adapted from the guidelines that govern health in other forms of sport. At this time, we recommend that the sports medicine practitioners caring for jockeys develop a working knowledge of nutrition, bone health, mental health of the athlete, and management of on-field trauma. We further recommend that injured riders be evaluated in simulated settings (i.e., with the equicizers) prior to return to riding.

Future research must build on the existing published literature to further identify modifiable factors that contribute to injury and morbidity. These investigations should inform safety policies used by professional organizations and racetracks. Further research is needed to explore the prevalence of substance abuse among jockeys and describe the need for services for this neglected population of athletes. Modernization and integration of medical record-keeping among sports medicine practitioners will facilitate improvements in care and improve the accuracy and speed of injury reporting by offering more real-time research data.

As the general public continues to engage in a discussion of safety in sports with respect to brain trauma among American football players, there is an opportunity for sports medicine physicians and athletic trainers to lead the horse racing industry in an ongoing effort to modernize safety and improve health on and off the racetrack. With many participants in the industry, it is incumbent upon the medical profession to adopt an active role guiding stake-holders to invest in the health of these courageous athletes to ensure the longevity of one of the world’s oldest sports.

This article is dedicated to our riders, who have taught us so much. It is an honor to work with you and watch you ride. The authors also would like to acknowledge those that have dedicated their time and been pioneers in research to this cause, including but not limited to Michael Turner, Peta Hitchens, and all of our racetrack science colleagues from Ireland. We appreciate the support and mentorship from Medstar colleagues, Maryland Racing (MJC, MTHA) as well as our families who support our endeavors. Max Romano and Erica Gaertner thank you for your recommendations. Special thank you to Maryland Horsemen's Health Program and Diana Pinones for their help with our research, articles, and most importantly all they do to ensure our jockeys receive the best care. ~ Kelly Ryan

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Additional Resources

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