Rodeo differs from other sports in regard to its athletes' independence from conventional health care systems. This has, in part, led to a paucity in recent related sports medicine literature. Only four articles on rodeo injury were cited in a search of the National Library of Medicine for the years 2005 and 2006 [1•,2,3,4••]. Despite limited literature regarding this issue, the rodeo factors of high speed and large bodies of mass in motion combine to create high kinetic energy and high potential for serious injury. This article reviews rodeo demographics, quantifies the types of injury seen in different rodeo events, evaluates mechanisms of injury, examines relevant literature reports, and considers how well the health care system interacts with rodeo athletes.
The sport of rodeo derives from ranching and skills used in handling livestock. Rodeo competitions occur throughout much of North America and range from youth to professional competitions. Individual rodeo events are divided into “timed events,” which include steer wrestling, barrel racing, team roping, and calf roping, and “rough stock” events, which include bull, bareback, and saddle bronc riding. Seven hundred and fifteen professional rodeos take place annually in the United States and Canada [4••], and nearly 20 million spectators attend professional rodeos annually . The organizations that oversee the majority of rodeo competition are the National High School Rodeo Association, National Intercollegiate Rodeo Association, Professional Rodeo Cowboys Association, Canadian Professional Rodeo Association, International Pro Rodeo Association, Professional Bull Riders, and the Professional Canadian Bull Riders.
Statistics compiled by the Justin Sportsmedicine Team [6••] in attendance at 1939 Professional Rodeo Cowboys Association rodeos from the years 1981 through 2005 separated out injury numbers due to different events and anatomical location: 49.8% of injuries occurred in bull riding, 22.8% in bareback riding, 15.6% in saddle bronc riding, 8.0% in steer wrestling, 2.7% in calf roping, and 1.1% in team roping. Barrel racing was not included in this compilation. The head and/or face, knee, and shoulder were most commonly injured.
These injury numbers differ somewhat from those reported in 2002 for a 5-year prospective epidemiologic analysis of Canadian professional rodeos in which bull riding accounted for 31% of injuries. In the Canadian study, women's barrel racing was included and found to be responsible for 1.5% of injuries. In this study, injury incidence density was used as the statistical measurement and found to be 14.7 injuries per 1000 competitor-exposures overall .
The prevalence of injury in rodeo athletes was studied at the University of Washington in a survey of 180 participants in the Indian National Finals Rodeo in 2004 [1•]. The response rate was 94%. The history of injury was variable according to event. One hundred percent of bull riders had been injured, while only 24% of tie-down ropers had been injured. Twenty-six percent of the athletes had sustained injuries that prevented them from working an average of 3.2 months. In this study, the use of protective equipment was also surveyed, with the finding that 40% of athletes used protective equipment, mostly protective vests.
Further evidence of the high prevalence of injury in rodeo was provided by Meyers et al.  in 2003. The authors studied upper extremity radiographs in 25 rough stock athletes competing in bull riding and bareback riding at a College National Finals Rodeo. Twenty-four hand and wrist fractures, both healed and unhealed, were identified. Fourteen athletes had radiographic evidence of arthritic change and/or joint instability in the hand and wrist. Twelve showed evidence of ulnohumeral degenerative joint disease in the elbow and three had loose bodies in the elbow . The author has encountered advanced elbow degenerative disease in former rough stock riders (Fig. 1 and 2).
Mechanism of Injury
Assessing mechanism of injury in rough stock events is a fascinating but gory study. Injury can be incurred while on the animal, be it bull or bronc, or during the dismount. The dismount can be voluntary (once the mandatory 8 seconds have elapsed) or involuntary (by being thrown off). Injuries incurred while on the animal may include elbow, wrist, and hand injuries, such as those documented radiographically by Meyers et al. . Pelvic injuries such as pubic diastasis may occur through a wedge effect of the animal's back during bucking (Fig. 3). Concussions may occur during the ride through a whiplash effect or impact against a horse's hip  or a bull's head [9,10]. The rider may also be slammed against the chute gate or the arena rails .
Injuries that occur once the athlete is thrown or dismounts may affect various body parts and usually involve moderate to high energy. Stomping and goring injuries after the dismount produce a mechanism for very violent and occasionally fatal injury. Aortic transaction and ventricular septal rupture have been reported [12,13]; permanent brain and spinal cord injury may ensue [9,10]. In the author's experience, a heart-rending matter for the spectator is the failed dismount, when the athlete's hand is hung up in the rope on the animal and the athlete is dragged and whipped accordingly. This may cause frank upper extremity fracture or severe ligamentous injury.
Steer wrestling provides its own mechanisms for injury. This event involves loping on horseback at a full sprint, lunging off onto a 500-lb steer, grabbing the steer's horns, applying deceleration by digging in heels, and wrestling the steer to the ground. The event may feature goring injuries to the chest and head. The Justin Sportsmedicine Team [6••] reports that the most common injury in steer wrestling is knee injury followed by shoulder injury and ankle injury. Chronic ailments such as an anterior cruciate ligament–deficient knee or recurrently dislocating shoulder may ensue.
Another event, which is minor yet deserves mention for its injury potential, is the wild horse race. In this event, three men grab the halter of a wild horse released from a chute and endeavor to hold the horse, saddle it, and mount one of the team members, who then has to ride between a barrel and the fence on the other side of the arena. About 10 teams of men and wild horses compete simultaneously, with the horses bucking and often running wildly, smashing into each other and the men. Butterwick et al.  found the highest incidence of injury of all events in wild horse racing at a rate of 53.0 injuries per 1000 competitor-exposures.
Bull Riding and Concussions
The spectator's intuition that bull riding is an extremely dangerous sport'especially upon watching down into the chutes while the athlete tightens the rope holding his hand to the bull'is well borne out statistically. The 5-year epidemiologic analysis in professional Canadian rodeo by Butterwick et al.  showed an incidence of 32.2 injuries per 1000 competitor-exposures. The Justin Sportsmedicine Team [6••] reported that bull riding accounted for more than 50% of rodeo injuries in all years between 1981 and 2005 except for 1991, 1994, and 2002. Medical providers at a professional rodeo in Montana treated 70% of the bull riders for injury . Bull riding is unquestionably “one of the most dangerous sporting events of the modern era” [4••]. This is due to the extraordinary power of the bull and its natural desire to attack and kill its rider. Witness the behavior of the bull rider after he dismounts from the bull.
While knee and shoulder injuries are common in bull riding [6••], head injury is most alarming. Concussions account for 8.6% of all bull riding injuries, as reported by Butterwick et al. . In regard to this matter, a joint statement was issued from the First International Rodeo Research and Clinical Care Conference in Calgary in 2004 [4••]. The recommendation for mitigating head injury was that bull riders 18 years and older be encouraged to wear headgear (helmets with face guards) and that bull riders younger than 18 years of age be required to wear headgear. In addition, the group recommended having physicians available at rodeos to assess and manage concussions; if physicians are not available, then bull riders with a prior concussion would be required to produce a letter of medical release prior to returning to competition. Barring either of these, there was a recommendation to restrict participation for 1 week after concussion in the athlete who is symptom free. Nonetheless, these recommendations are far removed from actual practice. Protective headgear is rarely used and is not required by most rodeo organizations. In addition, with the exception of high school rodeo, organizers do not require medical clearance for return to participation after injury .
As expected, some evidence exists that headgear is effective in reducing the rate of head injury in bull riding. Brandenburg and Archer  reported that bull riders were able to decrease head injury rate from 1.54% to 0.80% per ride through the use of helmets. A related study in the pediatric literature showed that helmet use in horseback riding reduced the number and severity of head injuries .
Injuries are rare in calf and team roping but can be devastating when they occur. Digit amputation, especially of the thumb, occurs when the digit is caught in a loop of rope against the horn of the horse saddle. This happens in the process of “–dallying” (securing the rope by taking wraps around the horn). In a mechanical analysis of a 500-lb steer (227 kg) running at 30 mph, the force of the rope on the digit was estimated at 16,544 N for “heading” (roping the head of the steer) and 13,297 N for “heeling” (roping the hind legs of the steer) . Digital entrapment injuries involve elements of avulsion and crush, rendering a poor prognosis for replantation success. Moneim et al.  reported that only 5 of 15 digit replantations were successful for roping amputations. Kirwan and Scott  reported a 59% success rate for digit replantation and/or revascularization after roping injury. Isenberg  showed a higher ultimate success rate of 70% with these injuries but had a 43% rate of complication and common need for reconstructive measures.
One important aim of sports medicine is injury prevention. In rough stock events, protective vests have likely reduced the rate of rib fractures, penetrating chest injury, and pneumothorax. Headgear has been found to reduce the rate of head injury in bull riding . While vests seem to be well accepted by rough stock athletes, however, acceptance of headgear is limited. One must wonder if the limited use of coaching in rodeo is partially responsible for the phenomenon. The “machismo” culture of rodeo certainly plays a part in lack of headgear acceptance. While medical teams have implemented preventative measures in some venues, the widespread and disjointed nature of the sport prevents universal measures from being applied.
Some authors have recommended measures such as prophylactic elbow braces to prevent sprains and hyperextension injuries in rough stock events. The individual use of limited protective measures such as elbow sleeves and tape is common, although one rarely sees actual use of mechanically sound elbow braces. Another suggestion for prevention of injury in roping events has been to avoid dallying through the use of a clip holding the rope to the saddle . This measure is unlikely to be adopted as it is an extreme departure from the traditional roping method. Solid attachment of the rope to the saddle may allow a pull by the steer to turn the saddle, creating potential for injury from this mechanism.
Rodeo and the Health Care System
The relation of the health care provider to the rodeo athlete bears examination. How does the health care provider conceptualize the sport of rodeo? How can the health care industry help the rodeo athlete? Providing information on benefits of protective equipment will certainly be helpful. Compliance, of course, will be another matter. It seems reasonable to advise the national and local rodeo associations and organizers to change rules to require protective vests and headgear for rough stock athletes, especially bull riders.
Perhaps the health care provider can most benefit rodeo athletes through greater availability at rodeo competitions. The national rodeo organizations require emergency medical services attendance at rodeos but not physician attendance. Physicians, however, are welcomed at rodeos. It has been the author's experience and that of others  that the rodeo cowboy is very grateful for medical help at the side of the arena. Nebergall  has accurately pointed out that many rodeo cowboys suffer from chronic injury yet rarely seek medical attention; therefore, it is likely that physicians at the arena-side may help the rodeo athlete with chronic as well as acute injuries.
In summary, this article has reviewed the demographics of rodeo, outlined injury patterns in different rodeo events, described ideas on injury prevention, and questioned the relation of the health care provider to the rodeo athlete. Our hope is that the sport of rodeo will be made safer for the athlete through greater physician interaction with the rodeo organizations and athletes in the future.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
1.• Crichlow R, Williamson S, Geurin M, Heggem H: Self-reported injury history in Native American professional rodeo competitors.Clin J Sport Med
Interesting study of the prevalence of injury at the Indian National Finals Rodeo in 2004.
2. Shannon AL, Ferrari R, Russell AS: Alberta rodeo athletes do not develop the chronic whiplash syndrome.J Rheumatol
3. Brandenburg MA, Archer P: Mechanisms of head injury in bull riders with and without the Bull Tough helmet: a case series.J Okla State Med Assoc
4.•• Butterwick DJ, Brandenburg MA, Andrews DM, et al.
: Agreement statement from the 1st international rodeo research and clinical care conference: Calgary, Alberta, Canada (July 7–9, 2004).Clin J Sport Med
This consensus statement provides sound guidelines for prevention of injury, especially concussion in rough stock events.
5. Kotarba JA: Conceptualizing sports medicine as occupational health care: illustrations from professional rodeo and wrestling.Qual Health Res
6.•• The Justin Sportsmedicine Team: Rodeo Injury Report: 25 Years PRCA Injury Study. McKinney: Mobile Sports Medicine Systems, Inc.; 2006.
Great statistical review of rodeo injuries with a breakdown by anatomical location and rodeo event.
7. Butterwick DJ, Hagel BE, Nelson DS, et al.
: Epidemiological analysis of injury in five years of Canadian professional rodeo.Am J Sports Med
8. Meyers MC, Sterling JC, Souryal TO: Radiographic findings of the upper extremity in collegiate rodeo athletes.Med Sci Sports Exerc
9. Centers for Disease Control and Prevention (CDC): Bull riding-related brain and spinal cord injuries'Louisiana, 1994–1995.MMWR Morb Mortal Wkly Rep
10. Schmidt A, Brandenburg MA: Central nervous system injuries associated with bull riding, Oklahoma, 1992–1995.
In Injury update, Oklahoma State Department of Health. Oklahoma City: Injury Prevention Service of Oklahoma State Department of Health; 1997:1–5.
11. Griffin R, Peterson KD, Halseth JR, Reynolds B: Injuries in professional rodeo: an update.Phys Sportsmed
12. Tripp HF, Robicsek F: Aortic transaction secondary to rodeo injury.Mil Med
13. Yetman AT, McDonnell WM, Pye S, et al.
: Ventricular septal rupture in an amateur rodeo rider.J Trauma
14. Griffin R, Peterson KD, Halseth JR: Injuries in professional rodeo.Phys Sportsmed
15. Brandenburg MA, Archer P: Survey analysis to assess the effectiveness of the bull tough helmet in preventing head injuries in bull riders: a pilot study.Clin J Sport Med
16. Bond GR, Christoph RA, Rodgers BM: Pediatric equestrian injuries: assessing the impact of helmet use.Pediatrics
17. Moneim MS, Firoozbakhsh K, Gross D, et al.
: Thumb amputations from team roping.Am J Sports Med
18. Kirwan LA, Scott FA: Roping injuries in the hand: mechanism of injury and functional results.Plast Reconstr Surg
19. Isenberg JS: Rodeo thumb: an unusual etiology of avulsion amputation of the thumb.Ann Plast Surg
20. Nebergall R: Rodeo.
In Epidemiology of Sports Injuries. Edited by Caine DT, Caine CG, Lindner KJ, eds. Champaign: Human Kinetics; 1996:350–356.