Characteristics of Equestrian Injury Accidents and Injuries Leading to Permanent Medical Impairment

doi:10.21203/rs.3.rs-3953950/v1

Background: Equestrian sports are practiced all over the world and are a popular leisure activity in Sweden. Equestrianism is the country's second-largest youth sport. Previous studies indicate that equestrianism is accident-prone. However, few previous studies have examined acute equestrian injuries leading to permanent medical impairment.

Methods: By using nationwide insurance data including all injured equestrian registered in the Swedish Equestrian Federation, the objective was to examine acute injuries. The injury incidence and injuries leading to permanent medical impairment were examined. All equestrians injured during 2017-2021 were included (n=6876). Injury incidence was calculated separately for males and females as well as for different age groups by dividing the number of insurance claims by the number of members and multiplying by 1000. Risk Ration was calculated between gender. Pearson’s chi-squared test was used to analyse differences in distributions for categorical variables.

Results: The majority of injuries affected females, correlating with an almost three times higher risk compared to males. Those aged 21-40 years were associated with the highest injury risk (14.26/1000 registered riders). In total twelve percent of all injuries led to permanent medical impairment. Injuries to the upper and lower extremities, along with fractures, had a higher risk of resulting in an impairment.

Conclusions: The predominant injuries resulting in permanent medical impairment were arm and leg injuries, but to prevent the most serious injuries that significantly affect the rider's daily life, efforts to prevent head and spinal cord neck injuries should be implemented. Head injures remain the most frequent, serious and the most important injuries to prevent and mitigate within equestrian sports.

equestrian

injury

injury incidence

prevention

Globally, horse riding is emerging as a significant public health concern, with statistics showing an alarming frequency of acute injuries and even fatalities linked to equestrian accidents (1-3). Riding is a high-risk sport due to the elevated position of riders on powerful horses, horse speed, and the unpredictability of horse behavior (4), making it different from many other sports.

Previous studies on Swedish equestrian injuries show that accidents affect all ages (3, 5-7), but that the highest risk of injury is found among riders aged 21–40 years (8.83/1000 registered riders)(6). On average, there were three fatal accidents a year between the years 1997–2014 (7). Several studies have shown that the rider is usually injured when falling from the horse (3, 6, 8, 9). Other common causes of injury are the rider being bitten, kicked, or trampled. An overview by Meredith et al. (8) shows that the type and location of injury depends on the activity performed (e.g. riding and handling a horse). In addition, the injury pattern changes with the rider's age (6, 7, 10). The head is the most frequently injured region4(11) and equestrian sports have been identified as one of the greatest contributors to sports-related TBI (12). Furthermore, almost half of equestrian riders (44%) experienced concussions during their careers (13).

Few studies have had the possibility to study if long-term consequences arise from equestrian injuries. The existing studies primarily focus on serious injuries that required hospital care often treated at a trauma centre. Thereby, the injuries leading to long-term consequences are as high up to haft of the injuries (see for example (14-17)). The Swedish insurance company, Folksam Insurance Group (Folksam), has been the insurer for all members of the Swedish Equestrian Federation since 2017, which entails the possibility to verify and follow injuries leading to long-term consequences, denoted as permanent medical impairment. Since all members are included, the data set makes it possible to evaluate incidence rates. There is a lack of studies regarding equestrian injuries that lead to permanent medical impairment.

The aim of this study was to analyze characteristics of equestrian injury accidents and particularly injuries that lead to permanent medical impairment.

Folksam offers comprehensive insurance coverage to all members of the Swedish Equestrian Federation, covering everyone from beginners to competitive athletes. The insurance covers every member during training, Swedish Equestrian Federation activities as well as competitive riding. This five-year retrospective study included all horse-related injuries among all members of the Swedish Equestrian Federation that were reported to Folksam between 1 January 2017 and 31 December 2021 (n=6876). From 2017 to 2021 the number of registered members has increased from 138 511 to 143 516. Both exposure on individual level and injury data were used.

An eligible injury was defined as an acute injury reported to the sport injury database of Folksam that had occurred while participating in an activity with or related to horses. This included horse riding and horse care activities in conjunction with either training or competition. An acute injury is defined as an injury resulting from a specific identifiable event. Injuries were reported by the rider, or a parent if the rider is a minor, via telephone or online. All riders that have been examined by a physician within one week from the accident date were included in the present study. Thereby, all injuries irrespective of healthcare and injury severity were included. Most of the injuries were diagnosed by a physician, but some were also examined by other experts, such as physiotherapists. The injuries were categorised in different categories regarding type of injury and body location. The injured body region was categorized into five groups: head and neck (including face), torso, upper extremities, lower extremities. The type of injury was based on the classification made by claims adjusters including the following seven groups: fracture, dislocation/rupture, sprain/strain, laceration/abrasion/contusion, concussion, and “multiple injury types”. Multiple injuries that occurred at the one and the same occasion were recorded as one injury category “rider with multiple injuries”.

Occasionally, an acute injury can result in a permanent medical impairment (PMI) leading to lifelong complications (18). The insurance is a complement to the national health care systems and compensates costs directly in connection with the accident as well as non-recurring monetary compensation if the injury results in PMI. The assessment will be done according to the guidelines Grading of Medical Impairment Degree (19). The principles of grading medical impairment were developed in the beginning of the 20th century and established in consensus with physicians. The injury is given a degree of PMI between 1 and 99 percent and regardless of the claimant’s profession or hobbies. Examples of degree of impairment are: 7% for an unstable ankle joint, 5-20% for a shoulder with maximal flexion of 0-120°, 37% for loss of one hand, 68% for total blindness, 99% for severe dementia. Before a PMI is established, a preliminary degree can be given because the long-term consequences of the injury can be difficult to estimate. A total of 357 personal injuries resulted in PMI in the years 2017 to 2021, but as it takes at least two years and, in some cases, significantly longer to determine if the injury will result in a permanent impairment, only injuries that occurred in 2017 and 2018 were used to analyze the risk and the injury distribution of injuries leading to PMI. The incidence of PMI was calculated as a proportion of all registered injuries during these two years.

Data included information on age (0-6, 7-12, 13-20, 21-40, 41 years or older, predefined by the Swedish Equestrian Federation) gender, date of injury, nature of injury and injured body region. Additionally, claimants were required to provide a description of the injury event, which was then categorized into the type of activity (horse riding, horse handling or other horse care activities) and the incident type (fall, kick, bite, trampled, crushed, or knocked by horse, caught in equipment, other). The study was approved by the Swedish Ethical Review Authority (Dnr 2018/711-31/5).

Statistical Analysis

Descriptive statistics, including frequencies and percentages, were conducted on all available variables using IBM SPSS Statistics version 28. Injury incidence was then calculated separately for males and females as well as for different age groups by dividing the number of insurance claims by the number of members and multiplying by 1000. This was expressed as “the number of injuries per 1000 members”. Risk expressed as risk ratio (RR) was then calculated between sexes by dividing the incidence of injury in females by the incidence in males. Pearson’s chi-squared test was used to analyse differences in distributions for categorical variables. All analyses were two-sided, and the significance level was set at p<0.05.

During the time between 2017 and 2021, 6876 riders made a claim to Folksam following an acute traumatic injury while participating in horse riding and horse care activities. Of these 6121 were unique individuals. Within the study period in total three riders were fatally injured. In total female riders were predominated, with 97 percent of the injured equestrians being female. The average age of the injured rider was 29 years, with a range of 3 to 80 years. The percentage of riders injured in the different age‐groups compared with all registered members can be seen in Figure 1. The proportion of injuries was highest among older age groups.

Injury incidence

The overall injury incidence rate was 8.98 injuries per 1000 registered riders per year, Table 1. Females were associated with almost three times higher risk of injury than males (RR=2.71), having an injury incidence of 9.47 compared with 3.49 for males. At the same time, men had a higher average age than women. The average age among women was 29 years (range 6-75 years) while 38 years (range 3-80 years) for men. Those aged 21-40 years were associated with the highest injury incidence (14.25/1000 registered riders), while 0-6-year-olds had the lowest (1.51/1000 registered riders).

Table 1. Injury Incidence, concussion Incidence and PMI Incidence for different age groups and gender.

Category	Injury Incidence	Concussion Incidence	*PMI Incidence**
0 – 6y	1.51	0.28
7 – 12y	4.90	1.02
13 – 20y	8.94	2.27
21 – 40y	14.25	2.33
41+ y	10.18	1.02
Female	9.47	1.69	2.08
Male	3.47	0.43	0.60
Total	8.98	1.59	1.95

*Permanent Medical Impairment

Injury characteristics

Among the 6876 equestrians involved in accidents, a total of 7768 injuries were reported, resulting in an average of 1.1 injuries per individual. Aggregated data on body region shows that the most injured body region was the “head and neck” (44%) followed by upper extremity (28%), Table 2. The most frequently seen injury types were soft tissue injuries (34%) and fractures (32%), Figure 2. Concussion was also commonly occurring, accounting for 18 percent of all injuries. Those aged 13-20 years or 21-40 years were associated with the highest incidence of concussions (2.27-2.33/1000 registered riders) although the proportion of concussions were highest among riders younger than 21 years of age (p<0.001), Table 1. Fracturs were, on the other hand, higher among riders older than 20 years of age (p<0.001). There was a higher proportion of concussions among female riders (p=0.038) but there was no difference among gender for fractures.

The predominant incident type was falls from horseback, making up 84% of incidents, followed by kicks at 4%, entanglement in equipment at 3%, and being trampled by a horse at 2%. Among riders with multiple injuries, a slightly higher proportion experienced incidents falling of horseback while riding (88%). Falls were the primary cause of injuries during riding, whereas kicks usually happened during horse handling and mounting/dismounting activities. In total 87 percent of the injuries occurred while riding, nine percent during horse-handling and two percent while mounting or dismounting.

Table 2. Distribution of injuries and injuries leading to permanent medical impairment (PMI) by body region.

Body Region	Number and proportion of Injuries (based on all cases)		*Number of Injuries Resulting in PMI (based on injuries that occurred 2017-2018)**
Head and Neck injuries	2996		34
Head/brain	605	20%	7
Concussion	1215	41%	8
Face	254	8%	8
Eye	19	1%	-
Teeth	121	4%	-
Cervical Spine	157	5%	5
Riders with multiple injuries including head/ neck injuries	577	19%	6
Unknown	48	2%	-
Upper Extremity	1950		133
Shoulder	758	39%	29
Upper Arm	160	8%	15
Elbow	103	5%	10
Forearm	100	5%	10
Wrist	266	14%	23
Hand/Finger	487	25%	45
Riders with multiple injuries including upper limb injuries	34	2%	1
Unknown	42	2%	-
Torso	1139		50
Sternum/Ribs/Upper Back	651	57%	26
Abdomen incl. Organs	125	11%	1
Lower Back/Pelvis/Sacrum	212	19%	16
Spine, undefined	55	5%	3
Riders with multiple injuries including torso injuries	69	6%	4
Unknown	27	2%	-
Lower extremity	1592		97
Hip/Thigh	712	45%	19
Knee	259	16%	20
Lower Leg	160	10%	19
Ankle	202	13%	24
Foot/Toe	211	13%	14
Riders with multiple injuries including lower extremity injuries	25	2%	1
Unknown	23	1%	-
Unknown Body Region/Other Type of Injury	91		1
Total Number of Injuries	7768		314
Total Number of Equestrians	6876		297

*Permanent Medical Impairment

Injuries leading to PMI

In total, twelve percent of all the injured riders during the years 2017 and 2018 sustained a PMI. Of these, 42 percent was an injury to the upper extremities, Table 2. Fingers followed by the shoulder were the most commonly parts of the upper extremities that were affected. The highest risks of sustaining a PMI for an injury was found for the upper and lower extremities (19% and 18% respectively), Table 3. However, head and neck injuries often resulted in a higher average degree of PMI than other injuries. The riders who received PMI of 10 percent or more had mainly suffered a brain injury or damage to the spine. Fracture was the most common type of injury leading to PMI, Figure 3. There was a higher risk that a fracture resulted in PMI compared to other injuries (p<0.001). Furthermore, riders with multiple injuries had a higher risk that any of the injuries resulted in PMI than riders with only one injury (p=0.01). There was no difference between gender. However, that an injury resulted in PMI was higher among riders older than 20 years of age (p<0.001). The average age of the rider with an injury resulted in PMI was 37 years.

Table 3. Number of injuries, injuries leading to PMI, risk of PMI and average degree of PMI by body region.

Injured Body Region	Total Number of Injuries (during 2017–2018)	Number of injuries leading to PMI* (during 2017–2018)	*Risk of PMI (%)**	Average degree of PMI* (min-max)
Head and Neck	961	34	4	12(1-90)
Upper Extremity	717	133	19	3(1-9)
Torso	471	50	11	4(1-14)
Lower Extremity	551	97	18	3(1-14)
Spine**	242	28	12	7(1-90)
Other injuries	16	1	6	7(-)
Total Number of Injuries	2958	314	11	4(1-90)
Total Number of Riders	2450	297	12	4(1-90)

*Permanent Medical Impairment

**Included as a subset in Head and Neck, Torso and Lower Extremity

The majority of injuries resulting in PMI occurred during riding activities (74%), primarily resulting from falls off the horse (93%). About 18 percent of PMI cases stemmed from horse handling, with kicks or entanglement in equipment being the primary causes. Irrespective of the activity, falls constituted the most common cause of injury (70%), followed by being kicked by the horse (7%) and getting caught in equipment (7%).

In this retrospective cohort study evaluating injured members of the Swedish Equestrian Federation spanning all age groups, it was found that around 1400 riders annually report equestrian injuries via their insurance. This corresponds to approximately 26 injured riders per week. Notably, injures affect riders across all ages, with the average age of those being injured being 29 years. It is often highlighted that younger riders are injured. This holds true in terms of raw injury numbers. However, when the injured riders are put in relation to the proportion of practitioners in each age group the results from this study uncover a higher risk of injury among older riders.

In previous studies such as Meredith et al. (5) and Franzén et al (3) who studied admissions to healthcare facilities in one region of Sweden or one hospital trauma registry, they showed that most injured people were aged 10 to 21 years. Furthermore, another Swedish study estimated that approximately 9000 of those who are injured annually in equestrian activities need to visit the emergency department and that the largest proportion of injured people were found between the ages of 11-17 years (20). The average age of injured was 24 years in Franzén et al. (3) and 27 years in Meredith et al. (7), with the highest number of injuries in the age group 0-18 years. It is important to consider that these studies are based on all individuals who sought medical care after a horse accident and are not in relation to how many that practice these activities. Furthermore, it is not clear how many of these were injured within the activities of the Swedish Equestrian Federation. In the present study the results are based on Folksam's injury data, which only contains members of the Swedish Equestrian Federation and where the data was set in proportion of injuries in relation to the number of members.

However, there are some international studies that show that both the number of injuries and the risk of being injured differ between ages when riding (6, 10, 21, 22). Like the present study, Smartt and Chalmers (21) found comparable average ages and noted that females tended to be younger and more frequently injured than males. However, the incidence rates were based on general participation in equestrian activity and not membership of equestrian federation. This difference makes it challenging to directly compare these findings to the data in the present study. Acton et al (23) demonstrate parallels with the present study regarding that most horse-related injuries were diagnosed as a fracture or soft tissue injury. Furthermore, similarities were found when studying female riders. They were more likely to sustain a head and neck injury as well as being diagnosed with a concussion compared to male riders. Similarly, younger riders were more likely to have a head and neck injury or be diagnosed with a concussion than older riders. In the present study older riders had a higher risk of both injuries and injuries leading to PMI. This aligns with findings from a study using German data (11), emphasizing the importance of considering older individuals as a target group in efforts aiming at preventing serious injuries. A literature study by Meredith et al. (8), however, show few studies that indicate that the elderly has a higher injury rate. This is mainly due to more younger riders being included in the studies. Acton et al. (23) highlights the need for more studies that include older riders.

Regarding equestrian injuries leading to long-term consequences Ball et al. (17) showed that a high number of orthopaedic related injuries resulted in residual functional deficits, supporting the finding of the present study showing that fractures more often resulted in PMI compared to other injuries. In total twelve percent of all the injured riders during the years 2017 and 2018 sustained a PMI. While this figure might appear to be lower in contrast to previous study (17), it is important to note that the present study includes all injuries, irrespective of healthcare and injury severity. Permanent medical impairment was higher among riders older than 20 years of age. There are several reasons for this. A medical impairment is considered permanent when no further improvement in physical and/or mental function is expected with additional treatment. The medical impairment injury is monitored until the permanent degree of medical impairment can be determined, which sometimes can take many years and cannot always be done until adulthood. This might explain why young riders had a lower risk that an injury resulting in PMI. However, previous studies have shown that in general the risk is higher for elderly (24, 25). Compare to studies involving individuals from other sports federations, such as the Swedish Cycling Federation, the risk that an injury from competitive cycling resulted in PMI was lower than that observed among equestrians (9% compared to 12%) (26). As a rider, you sit about three meters above the ground on an animal that can easily weigh 500 kg or more. High speed combined with falling from a great height is a major risk factor for severe injuries, not found in many other sports and activities.

Like several studies, the most common incident was falls from horseback (6, 10, 21-23). Falls from hoses also constitute the majority of the accidents with injuries leading to PMI. However, when studying injuries leading to PMI the proportion of accidents that occurred while handling a horse, with kicks or entanglement in equipment being the primary causes, becomes more significant (18% compared to 9% of all injuries). Hence, it is crucial to also consider that handling a horse present a notable risk of injury. This aspect have been highlighted by Krüger et al (11) and should be included when devising injury prevention strategies. For instance, adopting safety measures like wearing helmets and body protectors during horse handling could effectively minimize the risk of injuries.

One of the main strengths of this study is the use of high-quality insurance register data, with exposure data for the total Swedish Equestrian Federation population coverage and several years of follow-up. As mentioned, the PMI is assessed by the insurance company at the earliest two years following an injury, thus PMI was based on only data for the years 2017 and 2018. If the policyholder has an agreement with more than one insurance company, all companies will compensate for the PMI but not for the acute injury. This might exaggerate the risk of injuries leading to PMI.

During Swedish Equestrian Federation events, riders are required to wear a helmet while riding, and there is a growing recommendation for helmet use while on the ground. This should be further encouraged and enforced. The protective effects of equestrian helmets for head and facial injuries have been confirmed (27). In the present study, head and neck injuries accounted for 44 percent of all injuries and it could therefore be argued that the helmets are not efficient enough. However, one limitation with the present study was that it was not possible to investigate all accidents where the riders were wearing a helmet. The insurance data only allowed tracking of cases where compensation was claimed due to damaged helmets. Nonetheless, several studies have stated that helmets protective effect must be improved and should be designed specifically for the softer ground and impact surfaces typically seen in falls from horseback(28-30) .

This nationwide register study shows that approximately 1400 out of 155,000 members within the Swedish Equestrian Federation annually made a claim following an acute traumatic injury while participating in a horse-related activity. The incidence of being injured is therefore nine injured riders per thousand insured.

Younger riders are often highlighted as the most injury-prone group. However, this study highlight that those aged 21-40 years were associated with the highest risk of injury, whereas young riders (7-12 years old) had a comparatively lower risk. Preventive efforts should target older riders as well.

This study further confirms that falls from horses are the single largest cause of equestrian accidents, but also handling a horse present a notable risk of injury. Approximately, twelve percent of the injuries led to permanent medical impairment. Injuries to the upper and lower extremities, along with fractures, had a higher risk of resulting in an impairment. However, to prevent the most serious injuries that significantly affect the rider's daily life, efforts to prevent head and spinal cord neck injuries should be implemented. Therefore, head injures remain most frequent, serious and the most important injuries to prevent and mitigate within equestrian sports.

Ethics approval statement and consent to participate

The study was approved by the Swedish Ethical Review Authority (Dnr 2018/711-31/5). The right to perform research is regulated in the insurance agreement for which the participants have signed. The data is also regulated by GDPR.

Consent for publication

The participant consent is regulated in the insurance agreement. One of the terms of condition is that they consent to contribute to research.

Competing interests

Folksam Insurance Group was involved in providing data for the study since HS and MK are employed by Folksam Insurance Group. However, the organisation had no influence over analysis or presentation of results. The authors declare that they have no competing interests.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Funding Declaration

No funding.

Acknowledgements

Not applicable.

Authors' information

Helena Stigson Email: [email protected] ORCID: https://orcid.org/0000-0002-2409-1379

Maria Klingegård Email: [email protected] ORCID: https://orcid.org/0000-0002-1539-2006

Author Contributions

HS and MK planned and designed the study as well as analysed the data. HS drafted the manuscript that was read and critically revised by MK. Both authors approved the final version.

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No competing interests reported.

Characteristics of Equestrian Injury Accidents and Injuries Leading to Permanent Medical Impairment

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