Youth horse-related injuries (2014–2024): a scoping review of epidemiological and disciplinary insights

Abstract

Although horse riding is hazardous and injuries are common, young riders regularly engage in horse-related activities. To our knowledge, there have been no syntheses on youth horse-related injuries published during the past decade that employ a multi- and interdisciplinary research agenda (M-IDR) and that incorporate both quantitative and qualitative methods. Therefore, this scoping review aimed to (1) review studies on horse-related injuries among children and adolescents and (2) identify methodological and paradigmatic trends according to M-IDR. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews Checklist, we searched six databases (PubMed, SportDiscus, Scopus, PsycInfo, Sociological Abstracts and Web of Science) for studies on horse-related injuries among youth riders published between 1 January 2014 and 1 December 2024. The total sample included 1400 participants aged 0–17 years, of which 78.7% were girls. The main results present data on acute injuries in general and traumatic brain injury in particular. In terms of disciplinary insights, the study design and paradigmatic views predominantly reflect a positivistic worldview, employ quantitative methods and are consistent with previous literature reviews on equestrian sport injuries. Further studies are needed on the injuries that occur among young riders in equestrian sports. They should use an interpretivist approach to explore norms and attitudes towards injuries and risk-taking within the equestrian community, for example, how cultural predisposition influences safety equipment use among young equestrians in private stables.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Equestrian sport is a high-risk sport practised mostly by women and girls.

• Multi- and interdisciplinary research (M-IDR) approaches, as well as complexity theories, have become prevalent in youth sport injury research.

WHAT THIS STUDY ADDS

• Youth equestrian and youth sport research lacks integration across disciplines and paradigms.

• The field of medicine predominantly represents youth equestrian sport injury research and leans towards a positivistic worldview.

• This review synthesises youth equestrian sport injury research, reporting the most common injury types, mechanisms, severities, settings and helmet use between 2014 and 2024.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This review provides a theoretical and methodological foundation for M-IDR research on youth equestrian and youth sports injuries.

• The synthesis of child-specific injury patterns and trauma characteristics provides clinicians with evidence-based insights to enhance trauma assessment protocols and to improve clinical decision-making.

• The review emphasises the need for unifying helmet use and equestrian sport injury documentation, which should initiate the development of a consensus or pro forma system for reporting such injuries.

Introduction

Participation in sport entails a risk of sustaining injuries, especially in high-risk sports such as equestrianism or horseback riding. Previous research indicates horseback riding has a higher injury burden than motorcycling, skiing, football and rugby,¹,⁵ mainly because injuries are both common and often severe. Despite the extent of horse-related accidents, injuries and even deaths, millions of children and adolescents engage in equestrianism across the globe. Most recent literature reviews on the epidemiology of horse-related accidents demonstrated that they occur predominantly among young females, but in the older age groups, male injuries are higher.^{6 7} These reviews only included quantitative studies, most of which were conducted in the USA and used retrospective data collection from hospital records.

Furthermore, a critical review of horse-related risks suggested that an anthrozoological and multidisciplinary research approach, focusing on both horse-related and human-related risk factors, can provide a previously underexplored opportunity to mitigate horse-related risks for injuries.⁸ Moreover, both sport science generally⁹ and research on soccer-related injuries among youth specifically¹⁰ have suggested that a multi- and interdisciplinary research (M-IDR) approach can expand knowledge of injury aetiology. An M-IDR approach can generate an important opportunity to make horses safer mounts, humans safer riders and equestrianism a safer culture, thereby reducing accidents, injuries and deaths.⁸ Achieving an M-IDR study requires reviewing literature that provides relevant disciplinary insights, such as scientific paradigms and research methods,^{10 11} and in this case, it also requires reviewing injury research literature, which is specific to sport, experience level and age group.^{10 12}

Existing reviews on horse-related injury literature indicated a lack of knowledge regarding the current risks associated with horseback riding,^{8 13} the development of traumatic brain injury (TBI) documentation¹⁴ and appropriate safety equipment use.¹⁵ Finally, there is a need for further understanding of horse behaviour and stable culture concerning injury risk and epidemiology.^{8 16} Although some studies have recently reviewed the epidemiology of horse trauma⁶ and several have reviewed horse-related accidents and injuries,^{78 13},¹⁸ none have specifically focused on children, and only one seems to have included multiple disciplinary perspectives.⁸ To address this research gap, this review contributes to child-specific injury epidemiology and disciplinary perspectives. Therefore, we conducted a scoping review of the literature produced over the past decade to serve as a foundation for future M-IDR research on equestrian sport. In turn, research based on this review can improve riders’ quality of life, enhance lifelong sport participation, reduce hospital costs and decrease injury severity and frequency among riders worldwide. Thus, this review aimed to (1) review studies on horse-related injuries among children and adolescents and (2) identify their methodological and paradigmatic trends.

Methods

Scoping review

We used Arksey and O’Malley’s methodological framework for scoping reviews to map research gaps and key concepts.^{19 20} This five-stage framework provides a guide to identify research questions and relevant studies, select studies, chart data, and collate, summarise and report the results.²⁰ Furthermore, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews Checklist to strengthen the replicability of the review.²¹ In contrast to systematic reviews, scoping reviews are useful to assess broader topics and complex research areas,¹⁹ and they consider all literature as relevant regardless of its study design. Therefore, this review can provide a basis for future M-IDR by examining existing disciplinary perspectives in sport injury research at the theoretical and methodological levels.⁹,¹¹ Accordingly, it should be viewed as an extension of Hausken-Sutter et al’s work^{9 10} but with a particular focus on equestrian sport. Finally, to strengthen the review’s findings, we performed a quality assessment despite this not conforming to scoping review conventions.

Search terms and search strategies

Assisted by a librarian, we conducted an initial orientation to select key search terms regarding topic (injuries), sport (equestrian sport) and age group (children <19 years). Eventually, we combined the following keywords to facilitate the search strategy: (Injuries OR injury OR trauma OR “overuse injury” OR “acute injury”) AND (“equestrian sport” OR “horseback riding” OR “horse-related” OR “horse riding”) AND (“youth” OR “young” OR “adolescence” OR “children” OR “adolescents”). Between 2 and 3 December 2024, we searched the databases PubMed, SportDiscus, Scopus, APA PsycInfo, Sociological Abstracts and Web of Science (see online supplemental tables S1,S2).

Study selection criteria

Initially, studies including the overall population (all age groups) were included. Thereafter, only studies with children as the primary sample were included, and no restrictions were made regarding research design, methods or theoretical perspectives. Additionally, literature reviews and studies investigating horse-related therapy or treatment, such as rehabilitation or postinjury care, were excluded. Finally, studies published before 1 January 2014, or written in languages other than English, were excluded.

Quality assessment

To assess risk of bias, we used a modified Downs and Black checklist, which included 15 items rated as ‘2’, ‘1’, ‘0’ and ‘not applicable’. The total item score for each study was converted into a percentage, which subsequently enabled us to classify the studies as low (<50%), moderate (50%–75%) or high (>75%) quality. See each item score in online supplemental table S3. Initial disagreements between the authors regarding item scores (16.2%) were resolved in a consensus meeting. All reviewed studies had a mean quality score of 77.7%.

Charting, collating and summarising the data

Descriptive data from the relevant studies (n=7) were entered into an Excel sheet. The entries included information about study design, epidemiology and disciplinary insights. Inadequately described data were entered as N/A. To collate and summarise the entries, we followed the two steps suggested by Arksey and O’Malley’s framework.¹⁹ In the first step, the general study information was summarised (see table 1 and the descriptive summary). The second step involved a narrative presentation of epidemiological and disciplinary insights. The epistemological insights were inductively identified and collated into six themes (see table 2). The injury outcomes were related to the number of participants, the number of injuries or, in the worst case, a combination of both, leading to discrepancies in the total number of reported incidents. Data for the region of injury, injury mechanism and type of injury were mainly reported based on the number of injuries. In contrast, data for helmet use, injury context and horse-related injury were reported based on the number of participants. To clarify the ambiguities, we contacted the corresponding authors of four studies²²,²⁴ but unfortunately received no responses. Finally, the disciplinary insights were deductively identified and collated using the Integrated Model of Interdisciplinary Research Process, which assessed discipline, hypothesis, concepts, assumptions/methodology and insight into the problem for each study.¹¹

Table 1. Descriptive summary of the reviewed studies.

Author, year and country	Hypothesis/aim	Study design and time frame	Description of study population	Injury definition/categorisation
Cejudo et al (2020)27 Murcia, Spain	Predictors of lower back pain in child equestrian athletes include excess body composition, limited muscle flexibility, muscle weakness, asymmetry and misalignment of sagittal spinal curvatures.	Quantitative research	19 children (11 girls and 8 boys) aged 12–17 years M=14.7±1.9 Training camp	LBP >1 week or at least 3 days of training unattended due to LBP within the last 12 months
		Experimental
		Questionnaire, inclinometer (ROM-SPORT battery) and Tanita-305
		2017
Gross et al (2019)24 Jerusalem, Israel	Risk factors that increase injury severity include a lack of supervision, lack of experience and non-use of protective gear (eg, helmets, kneepads and hand protectors).	Quantitative research	53 children (11 girls and 42 boys) M=11.3±4.72 Trauma centre	ISS >15 categorised as severe trauma
		Retrospective
		Medical records
		2006–2016
Naef et al (2022)25 Geneva, Switzerland	The study examines injury incidence, severity and mechanism to expand the knowledge base on childhood equestrian injuries.	Quantitative research	501 children (433 girls and 68 boys) aged 2–15.9 years M=11±3 University hospital	Paediatric Trauma Score and ISS (cut-offs not stated)*
		Retrospective
		Medical records
		1990–2003, 2011–2018
Nguyen and Lew (2016)28, Milwaukee, USA	The injury pattern observed concerning a TBI affects the neurosurgical intervention in a paediatric population.	Quantitative research	Nine children (seven girls and two boys) aged 2.9–16.8 years Md=9.7 (3.6–15.8) Children’s hospital	GCS (cut-offs not stated)*
		Retrospective
		Medical records
		2005–2015
Short et al (2018)22 Salt Lake City, USA	Helmet use and TBI are underutilised during equestrian activity, and lack of use is associated with increased traumatic brain injury.	Quantitative research	142 children (77 girls and 65 boys) aged 1.5–17 years Md=11.0 (5.5–16.5) Trauma centre	ISS, Revised Trauma Score and GCS (cut-offs not stated)*
		Retrospective
		Medical records
		2005–2015
Theodore et al (2017)23 Brisbane, Australia	Helmet use and adult supervision prevent horse-related trauma in paediatric patients.	Quantitative research	171 children (158 girls and 29 boys) aged 0–16 years M/Md=N/A Children’s hospital	GCS 13–15=mild, 9–12=moderate and 3–8=severe imaging
		Retrospective
		Medical records
		2008–2014
Wolyncewicz et al (2018)26 Melbourne, Australia	The injury mechanism in relation to the horse (mounted vs unmounted) influences the severity of injury among children.	Quantitative research	505 children (405 girls and 100 boys) aged 0–15 years Md=12 (N/A) Children’s hospital	ISS <1=minor, 2–12=moderate, 13–25=severe and >25=critical Abbreviated Injury Scale 1–2=minor, 3=serious, and 4–5=major
		Retrospective
		Medical records
		2000–2015

GCS, Glasgow Coma Scale; ISS, Injury Severity Score; LBP, low back pain; N/A, Not Applicable; TBI, traumatic brain injury.

Table 2. Overview of epidemiological insights from reviewed studies.

	N	%
Injury context
Home/private facility/farm	410	49
Recreational or sporting facility	159	19
Public facility	49	5.9
Unknown/other	218	26.1
Injury in relation to a horse
Unknown	7	0.6
Known	1195	99.4
Mounted	971	81.3
Unmounted	224	18.7
Helmet use
Unknown	230	27.3
Known	613	72.7
Wearing	388	63.3
Not wearing	225	36.7
Injury mechanism
Fall	981	66.9
Fall+horse landed on patient	39	2.7
Fall+horse rolled over the patient	1	0.1
Kicked	200	13.6
Stomped/trampled	73	5
Bitten	14	1
Hit by a horse	13	0.9
Crushed by a falling horse	10	0.7
Rolled on	9	0.6
Hit by moving object/collision	2	0.1
Dragged	2	0.1
Thrown	1	0.1
Multiple mounted (eg, fall+ unmounted kick or fall+ unmounted other)	79	5.4
Unknown/other unmounted	42	2.9
Type of injury
Fracture	487	26.4
Traumatic brain injury	453	24.6
Contusion/soft tissue injury	345	18.7
Internal	153	8.3
Abrasion	35	1.9
Laceration	34	1.8
Joint dislocation	33	1.8
Low back pain	8	0.4
Sprain/distortion	8	0.4
Dental	2	0.1
Endocrine	1	0.1
Compartment syndrome	1	0.1
Other/unknown	284	15.4
Region of injury
Head/brain	475	25.5
Upper limb/extremity	394	21.1
Lower limb/extremity	223	12
Face	170	9.1
Abdomen	178	9.6
Spine	148	7.9
Thorax/chest	67	3.6
Extremity injury (limb unknown)	39	2.1
Back	26	1.4
Pelvis	24	1.3
Neck	19	1
Thigh	1	0.1
Hand	1	0.1
Other/unknown	98	5.3

Results

The initial search yielded 548 results. After removing duplicates (n=189), the first author screened the titles and abstracts and excluded studies that did not meet the inclusion criteria (n=312). Next, the remaining studies were read in full text, and those including both children and adults (n=39) and investigating multiple sports (n=1) were excluded. This process resulted in the final inclusion of seven studies (see figure 1).

Figure 1. Flowchart of study selection.

Descriptive summary

The total sample consisted of 1400 participants, of whom 78.7% were female. Except for one study, the samples predominantly comprised girls. The participants ranged in age from 0 to 17 years. The studies were conducted in Australia, Spain, the USA, Israel and Switzerland. The sample data sources were mainly hospitals and trauma centres, except in the Spanish study, which recruited participants from a training camp for youth competitive riders. The retrospective data collection periods spanned from 1990 to 2018, ranging from 1 to 20 years.

Narrative summary

The narrative results are presented below in two main sections: epidemiological insights and disciplinary insights.

Epidemiological insights

Injury context and in relation to the horse

Four studies reported the setting in which injuries occurred: 49% of the reported injuries took place at home or a private facility, 19% at a recreational or sporting facility and 5.9% at a public riding facility. Furthermore, five studies reported whether the rider was mounted or unmounted in the event of injury. Of a total of 1203 injuries, 80.9% (n=979) occurred while the rider was mounted and 19.1% (n=224) occurred when the rider was unmounted.

Helmet use

Helmet use was reported in four studies, involving a total of 843 participants (with known helmet use status, n=613; and unknown helmet use status, n=230). Of the participants with a known helmet use status, 388 (63.3%) reported wearing a helmet at the time of the accident. Accordingly, 225 riders (36.7%) did not wear a helmet at the time of injury. Only two studies reported on helmet use among mounted versus unmounted riders, showing that 350 out of 377 (92.8%) riders used a helmet while mounted and 9 out of 92 (9.8%) riders used a helmet while unmounted.

Injury mechanism

Six studies reported a total of 1466 injury mechanisms (eg, fall, kicked and stomped/trampled). Among those, falling was considered the most common, representing 66.9% of the injuries (n=981). The second most common injury mechanism was a kick (n=200, 13.6%).

Type, region and severity of injury

The total number of injuries across all studies was 1844, with several studies reporting multiple types of injuries. The most common type of injury was a fracture (26.4%), followed by TBI (24.6%) and soft tissue injury (18.7%). The head/brain was reported as the most frequently injured body region, accounting for 25.5% of the 1863 reported injury regions across all studies. Upper and lower limb injuries were the second and third most common regions, representing 21.1% and 12% of the injuries, respectively. In terms of injury severity, Naef et al²⁵ reported a range of 1–8 on the Injury Severity Score (ISS) with a mean of 2.65 (±1.25), while Gross et al²⁴ found an ISS range of 4–34 with a mean of 10.5 (±6.32). Wolyncewicz et al²⁶ recorded an ISS range of 1–6 and a median of 4, and Short et al²² observed a mean ISS of 7.1 (±5.5) for riders wearing a helmet compared with 11.3 (±6.5) for those without helmets.

Disciplinary insights

The reviewed studies share several disciplinary and methodological key features. All seven studies were published in the field of medicine and incorporated a positivistic paradigm. Overall, the studies focused primarily on acute injuries, especially TBI, and analysed the data using descriptive and inferential statistics. One study employed an injury definition related to low back pain, and the authors used an experimental design to focus on risk factors for overuse injuries that lead to lower back pain. The other six studies employed diagnostic tools, such as the ISS or Glasgow Coma Scale. Three studies used cut-off values for the score or scale, while the other three did not (see table 1). The studies’ most common concepts related to epidemiological factors. Moreover, the studies mainly focused on injury patterns and trauma characteristics, such as injury severity and mechanism.

Discussion

This scoping review aimed to compile findings on injuries among young riders (<19 years) published in peer-reviewed articles after 2014 and to identify epidemiological and disciplinary insights. Therefore, in contrast to previous reviews on equestrian injuries,⁶,⁸¹³ this report provides child-specific epidemiological insights and practical implications. In addition, this review also provides researchers with disciplinary insights as a foundation for future M-IDR agendas.

Most of the reviewed studies included both female and male participants. The majority of participants were girls (87.7%), but the studies did not clarify whether their samples were representative of the population being investigated. Moreover, only two studies discussed gender as a factor in their analysis.^{22 27} For example, one study concluded that lower back pain was linked with body fat greater than 23%²⁷; however, it did not consider gender, which could have affected the results. Consequently, we were unable to compile gender-based data. Therefore, our findings reveal that injury research that uses gender as a determining factor is rare. The high number of girls in the total sample is consistent with findings in previous literature reviews.⁶,⁸¹³ For instance, they show that the number of female riders is higher than that of male riders in several countries (eg, the USA, Australia, New Zealand, Norway and Sweden).

Our review indicates that falling is the most common mechanism of injury (66.9%), followed by being kicked (13.6%). The head is the most frequently affected region (25.5% of injuries), followed by the upper and lower extremities (21.1% and 12%, respectively). These results are concurrent with previous literature reviews, where falls and kicks accounted for most injuries, with concussions and upper-body fractures among the most common injury types.^{14 16 19} For instance, according to Young et al,¹⁵ soft tissue injuries are underreported compared with more severe injuries such as fractures, dislocations and head, neck or spinal injuries. The mentioned explanation is that soft tissue injuries often go unrecognised, whereas severe injuries are more readily diagnosed and reported. We concur with Young et al¹⁵ that by favouring hospital records for their data collection, most studies rely on riders who actively seek medical attention. Hence, future research should explore additional sources to capture less-reported or undetected injuries. The types of injuries that go unnoticed and the reasons they are not reported are closely tied to and can provide more insights into equestrian culture and norms.

Despite the prevalence of head injuries, only four of the studies reported whether the riders wore a helmet at the time of the accident. The remaining three studies reported having no information about helmet use. According to previous reviews, several studies have recommended the use of safety equipment, including helmets, vests and safety stirrups. Nevertheless, the reported helmet use among respondents in this review remains generally low. Moreover, previous reviews have noted considerable variation in the use of protective gear, ranging from 6% to 66.7%.¹⁵ Our review found that only 63.3% of the riders wore helmets, indicating significant room for improvement. Another review reported a reduction in neck and head injuries, attributing it to increased helmet use.¹³ Accordingly, increasing helmet use could minimise the risk of injury. In the future, helmet use documentation should be mandatory in the emergency room.

Furthermore, only one reviewed study investigated riders’ experience as a possible risk factor,²⁷ although five studies mentioned the importance of reporting experience as a risk factor.²²²⁴,^{26 28} In contrast, previous reviews revealed contradictory findings regarding experience as a risk factor: some reviews found that novice riders are at higher risk of injury,^{29 30} whereas others reported no correlation between rider experience and injury.³¹,³³ In addition, previous reviews identified horse behaviour as a risk factor,^{8 16} but only one review highlighted the equestrian culture itself as a risk factor.⁸ Therefore, we argue that future studies on horse-related injuries should consider more parameters about the setting that can affect the horse’s behaviour and subsequently increase the risk for injury. For instance, they should explore whether the injury occurred indoors or outdoors, whether the rider was alone or in a group of riders with several horses and whether the injury took place in a familiar or unfamiliar setting. Overall, more information about the setting is needed to understand the risk of injury in relation to horse behaviour.

Concerning disciplinary insights and the use of multiple perspectives in sport injury research, we have identified several characteristics. First, our results show that the studies were only published in journals within the disciplinary field of medicine and the subdiscipline of paediatrics. Moreover, the reviewed studies primarily focused on biomedical aspects, using quantitative methods and collecting retrospective data from trauma centres. Thus, this review reveals that equestrian injury research is predominantly monodisciplinary, and its study design leans towards a positivistic worldview rather than an interpretivist worldview. Similarly, previous reviews on horse-related injuries reported that most studies use a retrospective design and quantitative methods,⁸¹⁴,¹⁶ although their study samples consisted of both children and adults. Consequently, future research in sports medicine would benefit from interpretivist approaches to better understand norms and attitudes towards injuries and risk-taking within the equestrian community; it should also focus solely on injuries among young riders. For example, it could investigate unmounted horse-related activities in private settings (eg, home stables) from young riders’ perspectives. It also employed qualitative or mixed methods to explore how cultural predispositions within the equestrian community affect injury prevalence and incidence.

We aimed to review horse-related injuries from different disciplinary perspectives, but like previous reviews,⁶,⁸¹³ we found similar disciplinary perspectives among the reviewed studies. In summary, there is a notable lack of injury research addressing sociological (cultural) and psychological dimensions of injuries among young equestrians. Hence, using an array of disciplinary insights can deepen the understanding of horse-related human injuries among young equestrians. For instance, future research should investigate cultural factors, norms and attitudes, particularly among women who participate in horse-related sports and activities.

Limitations

This review excluded 39 studies that focused on both children and adults, which limited the findings because the data specific to children in these studies were not considered. Additionally, although the search strategy was developed with guidance from an experienced librarian, it was conducted by the first author, which may have introduced potential bias or oversight. Another key limitation is that several reviewed studies did not specify whether their reported figures referred to the number of injuries or the number of participants who were injured. This ambiguity prevented us from combining the data into an overall average and may have introduced inaccuracies in assessing the total burden of injuries. It also raised questions about potential double counting or undercounting in cases where individuals sustained multiple injuries. Consequently, these inconsistencies underscore the need to address reporting standards in the peer-review process, for example, by using the Strengthening the Reporting of Observational Studies in Epidemiology checklist³⁴ to enable more precise comparisons and meta-analyses in future reviews. A final limitation is that no registration protocol exists.

Conclusion

The primary conclusion of this scoping review is that further research is necessary to understand how equestrian norms and culture impact horse-related injuries among children and adolescents. This review has provided deeper disciplinary insights and, thus, a knowledge foundation for researchers aiming to investigate child-specific injuries in equestrian sport using an M-IDR agenda with quantitative and qualitative methods, resulting in three key practical recommendations. For practitioners, we recommend the use of helmets, as they significantly reduce the risk of severe head trauma and TBI in paediatric equestrian activities. This evidence-based recommendation aligns with established safety guidelines and reinforces the consistent use of helmets as a primary injury prevention strategy. Greater efforts are needed to ensure helmet use among children in private stables, especially while mounted, because falling is the most common injury mechanism. For clinicians, we suggest incorporating standardised data fields in trauma registries to document helmet use at the time of injury, enabling systematic analyses of protective equipment effectiveness. For researchers, we recommend employing qualitative methodologies to investigate the contextual factors surrounding unmounted injuries in private stable environments; these settings represent an understudied yet significant source of paediatric equestrian trauma.

Data availability statement

Data are available upon request.