Orthopaedic Injuries in Equestrian Sports

Abstract

Background:

Despite the common nature of orthopaedic injuries in equestrian sports, there is no published review to specifically characterize orthopaedic injuries in equestrian athletes.

Purpose:

To characterize orthopaedic injury patterns in equine sports–related injuries and their treatment.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

This review was performed through a PubMed, EMBASE, and Scopus query (from 1978 to June 2014) in the English literature using search terms “(equine-related OR equestrian-related OR horse-related OR equestrian OR equestrians) AND (injury OR injuries).” Only full-text studies reporting on orthopaedic injury patterns pertinent to equestrian sports in the United States (US) and the United Kingdom (UK) were included. Orthopaedic injuries were defined as those resulting in a fracture or dislocation. In all, 182 studies were excluded, leaving a total of 27 studies for evaluation. The studies included were analyzed for demographic and epidemiological data for orthopaedic injuries, including fractures and dislocations. Cranial and facial injuries were excluded from analysis.

Results:

The majority of those injured in the US were female (64.5%). The leading cause of injury in the US was falling from a horse. The use of protective equipment seemed to vary widely, with helmet use ranging from less than 6% up to 66.7%. In the UK, fractures were found to account for 17.4% of reported injures, compared with 33.6% of injuries in the US. The majority of fractures in US riders occurred in the upper extremities (50.7%).

Conclusion:

This review helps characterize the epidemiology of equestrian injuries based on currently available data.

Equestrian events form a popular international sport. The Centers for Disease Control and Prevention has estimated that approximately 30 million people ride horses annually in the United States (US).¹⁹ Of American riders, an estimated 2 million are younger than 19 years.¹⁵ While popular, equestrian disciplines have been found to be some of the most dangerous. Carmichael et al⁷ reported an injury rate of 1 for every 350 to 1000 hours spent riding. Further studies have indicated that though the sport has been found to have a lower injury rate than several other popular sports, it demonstrates a higher risk of severe injury compared with sports such as American football and automobile racing.^1,19 The severity of these injuries is likely due to the potentially dangerous position of the rider on a horse. Falls from a height at a high rate of speed may lead to a variety of injuries, including spine injuries, upper and lower extremity fractures and dislocations, and joint injuries. Some of these injuries may require surgery. While many injuries like this occur in young adults, riding poses particular dangers to children; erratic equine behavior may harm a child who might be less able to control the horse.⁹ In fact, several studies have demonstrated that trauma caused by horses can lead to severe injury, death, and long-term disability in pediatric patients.⁹

Despite the dangers posed by this sport and its widespread popularity, literature on injury patterns in equestrian sports or activities to date remains sparse, and only a single literature review has been published on equestrian injuries.¹⁹ Furthermore, previous studies have indicated that orthopaedic injuries account for as high as 30% of equestrian injuries.^13,19 However, only a single study has thus far focused on characterizing orthopaedic injury patterns.²⁴

The aim of this article is to review current literature to analyze equestrian injuries and to characterize patterns with respect to orthopaedic treatment. Demographic information will be analyzed to assess differences in patients’ age, sex, country, and other relevant information.³³

Methods

A review of the literature was performed through a search of PubMed, EMBASE, and Scopus (January 1978–June 2014 in PubMed, 1978-2014 in EMBASE, and 1978-2014 in Scopus limited to life and health science subject areas), using the search terms “(equine-related OR equestrian-related OR horse-related OR equestrian OR equestrians) AND (injury OR injuries)” to identify all English-language studies detailing equestrian injury patterns. From the searches, 161 results were returned from PubMed, 176 from EMBASE, and 184 from Scopus, yielding a total of 209 unique results. Of the 209 results, 200 full-text copies were able to be retrieved and assessed for eligibility. Only those studies presenting data pertinent to equestrian sports and orthopaedic injuries were included. Studies reporting exclusively on cranial and facial injury were excluded (n = 114). Furthermore, studies examining injury patterns outside the US and the United Kingdom (UK) were excluded (n = 43). Poster session and conference abstracts were also excluded (n = 4). Finally, all case studies and studies that focused on a single injury type (spine, podiatric, etc) without reporting on general injury patterns were excluded (n = 10). The study conducted by Norwood et al²⁹ was excluded due to a lack of specificity regarding the cause of equine injuries being attributable to horses, mules, or donkeys. The study conducted by Thomas et al³² was excluded because their data set overlapped with that of Loder,²⁴ whose study presented newer data. In all, 182 studies were excluded, and 27 studies were deemed eligible and were included in this review.

Several studies included in the review derived data from the National Electronic Injury Surveillance System (NEISS), which can be queried to provide national estimates based on cases seen in the emergency departments of 66 large national hospitals.^14,24 While the NEISS data are only estimates of true injury information and may be biased toward more severe injury, previous studies have found the NEISS to accurately reflect injury information, as estimates were shown to have an accuracy of 89% to 98%.²⁴

Included studies were then analyzed for demographic data and epidemiological data relating to orthopaedic injury, defined in this study as being all fractures or dislocations throughout the body excluding cranial and facial injury. Several of the studies included in the review did report cranial or facial fractures as a part of their data, though these were not considered orthopaedic injuries in our analysis. However, if a study did list head injury as the most common type of injury reported, it was noted.

Statistical Analysis

Orthopaedic injury incidence was tabulated for studies reporting in either the US or the UK. A distribution of orthopaedic injury incidence on the body was tabulated for both countries. A 2-sample z test of means was then calculated for each body region.

Results

In the 19 studies reviewed presenting injury data from the US, 17 did not explicitly state the sporting disciplines associated with the injuries reported. Press et al³⁰ focused on injuries in professional horse-racing jockeys, while Bernhang and Winslett³ presented injury data from the American Horse Shows Association, which governs equestrian sporting events in all disciplines. Injuries sustained in rodeos were excluded from their analysis.³ The majority of patients in the US were female (64.5%), and a large portion of patients reviewed were children (Table 1). Only a minority of riders were professionals. The leading cause of injury in the US was falling from a horse, while being kicked by a horse was frequently reported as being the second-leading cause (Table 2). Joint injury (dislocations) represented just a small portion of total injuries in the few reporting studies (from 0.3% [n = 15] up to 7% for jockeys [n = 29]), while fractures represented on average 33.6% of injuries. The majority of fractures occurred in the upper extremities (50.7%) and lower extremities (22.9%), with lower incidences in the spine, torso, and pelvis (Table 3). Fractures in the UK were found to account for 17.4% of all equestrian injuries reported, a significantly smaller proportion than the 33.6% reported in the US (P < .0001) (Table 4).

TABLE 1.

Demographic Data for Epidemiologic Studies of Equestrian Injuries

Study	Study Year(s)	No. of Study Subjects					Class of Rider
		Total	Pediatric	Adult	Male	Female
Barone and Rodgers2	1973-1987	136	136a	0	33	103	Pediatric
Bernhang and Winslett3	1979-1980	Unspecifiedb	Unspecifiedc	Unspecified	14.30%	85.7%	80% to 90% of riders in the study were amateursd
Bixby-Hammett4	1979-1982; 1987-1989e	Unspecified	Unspecified	Unspecified	Unspecified	Unspecified	Unspecified
Bixby-Hammett5	1995-1999	910	296f	614	Unspecified	Unspecified	Unspecified
Bond et al6	1990-1992	30	30g	0	11	19	Pediatric
Carrillo et al8	2000-2003	27h	Unspecified	Unspecified	12	15	4 professionals (14.8%)
Carmichael et al7	2003-2007	284i	Unspecified	Unspecified	145	139	85.6% amateur (n = 243)
Clarke et al11	1993-2004	76j	0	76	38	38	Unspecified
Cuenca et al13	Unspecified	164k	164	0	29	135	Pediatric
Fox et al14	2005	1200	Unspecified	Unspecified	Unspecified	Unspecified	Unspecified
Ghosh et al15	1995-1999	315	315l	0	118m	194	Pediatric
Griffen et al16	1994-1998	75n	Unspecified	Unspecified	42	33	67/75 riders injured in recreational activities
Grossman et al17	1976-1977	110o	Unspecified	Unspecified	84	76	90% amateur
Hobbs et al20	1986-1990	142p	Unspecified	Unspecified	67	75	Unspecified
Hughes et al21	1985-1992	32q	Unspecified	Unspecified	15	17	Unspecified
Loder24	2002-2004	5033r	1700	3333	1713	3320	Unspecified
Mayberry et al25	2003-2004	550s	Unspecified	Unspecified	Unspecified	Unspecified	12.4%t
Newton and Nielsen28	2000-2003	85u	Unspecified	Unspecified	53	32	Unspecifiedv
Press et al30	1990	706w	Unspecified	Unspecified	614	92	All professional jockeys

^aDefined as being ≤19 years old.

^bAmerican Horse Shows Association (AHSA) data set: 290 reported injuries; United States Pony Club (USPC) data set: 30 reported injuries.

^cAHSA data set: 63.1% accidents occurred in riders ≤18 years old; USPC: 89.3% of accidents occurred in riders ≤18 years old.

^dAmateur riders: 90.4% of injuries; professional riders: 9.6% of injuries.

^eData from the USPC and National Park Service excluded due to lack of a quantitative report.

^fDefined as being <24 years old.

^gDefined as being <15 years old.

^hMean age, 36 years (range,13-57 years).

ⁱMean age, 37.2 years (range, 2-79 years).

^jMean age, 42 years.

^kMedian age, 12 years (range, 3-18 years).

^lDefined as being ≤19 years old.

^m3 patients with unknown sex.

ⁿMean age, 37.0 ± 16.8 years (range, 3-81 years).

^oMedian age. 12 years (range, 3-18 years).

^pMean age, 27 years (range, 2-74 years).

^qMean age, 31 years (range, 12-55 years).

^rMean age, 30.0 ± 17.0 years (range, 1 month to 112 years).

^sMean age, 44 years (range, 6-83 years).

^tPercentage based on the 679 participants reporting.

^uRange, 2 to 77 years.

^v35% of riders reported to be “experienced” riders.

^wMean age, 30.8 years (σ = 7.5).

TABLE 2.

Injury Classification and Mechanism

Study	Fractures, % of Total Injuries Observed (n/N)a	Joint Dislocations, % of Total Injuries Reported (n/N)	Leading Cause of Injury	Second Leading Cause of Injury	Use of Protective Equipment	Most Common Class of Injury Overallb
Barone and Rodgers2	41.9 (52/136)	Unspecified	Fall from horse or being thrown (75%)	Kicked by horse (15%)	Unspecified	Head trauma (55%)
Bernhang and Winslett3c	Unspecifiedd	Unspecifiede	AHSA: fall from horse (refusal to jump) (23.04%) USPC: horse fall or slip (26.92%)	AHSA: horse fall or slip (22.17%) USPC: fall from horse (refusal to jump) (23.08%)	Unspecified	AHSA: fracture (15.5%) USPC: fracture (32%)
Bixby-Hammett4	26.50	2.20	Unspecified	Unspecified	Unspecified	Fracture (26.5%)
Bixby-Hammett5	34.9 (559/1604)	1.4 (23/1604)	Unspecified	Unspecified	Unspecified	Fracture
Bond et al6	30 (9/30)	Unspecified	All injuries evaluated were due to a fall from a horse		20 wearing helmets; 10 who were not	CNS
Carmichael et al7	34.2 (97/284)	Unspecified	Fall from horse (54%)	Kicked by horse (22%)	Helmet use confirmed in 6% of cases	Extremity fracture (33%)
Carrillo et al8	Unspecified	Unspecified	Unspecified	Unspecified	7/27 riders wearing protective gear	Chest injury
Clarke et al11	Unspecified	Unspecified	Fall from horse (68%)	Crush injury (15%)	Unspecified	Head and face injury (38%)f
Cuenca et al13	Unspecified	Unspecified	Fall from horse (82%)	Unspecified competitive event	Helmet usage in 14/34 cases reporting	Orthopaedic injuries (∼33%)
Fox et al14	Unspecified	Unspecified	Fall from horse (60%)	Stepped on by horse/kicked by horse (11% each)	Unspecified	Upper extremity
Ghosh et al15	15.7 (113/720)	0.3 (2/720)	Fall from horse (51.7%)	Kicked by horse (29.2%)	Unspecified	Head, neck, and face
Griffen et al16	Unspecifiedg	Unspecified	Thrown from horse (53%)	Kicked by horse (19%)	14% wearing helmets (10/72 reporting)	Extremity fracture
Grossman et al17	55.6 (35/63)	Unspecified	Unspecified	Unspecified	<20% wearing helmets	Closed head injury
Hobbs et al20	23.1 (34/147)	Unspecified	Fall from horse (63%)	Kicked by horse (17%)	Unspecified	Closed head injury (12%)
Hughes et al21	21	Unspecified	Falling from horse	Thrown from horse	6/32 wearing helmets	Head injury (44%)
Loder24	27.2 (1371/5033)	2.0 (100/5033)	Fall from horse (58.7%)	Thrown or bucked off horse (22.0%)	Unspecified	Fractures (28.3%)
Mayberry et al25	Unspecifiedh	Unspecified	Unspecified	Unspecified	61% of respondents wearing helmets	Extremity fracture (18%)i
Newton and Nielsen28	Unspecified	Unspecified	Fall from horse (53/85)	Kicked by horse (10/85)	>55% wearing helmets	Fractures
Press et al30	57.7 (1013/1757)	7	Fall from horse (jockey unseated) (69%)i	Horse fall (58%)j	Unspecified	Fractures

^aExcluding cranial and ENT (ear, nose, and throat) fractures. Mean total fractures: 33.6% (3283/9774). AHSA, American Horse Shows Association; CNS, central nervous system; USPC, United States Pony Club.

^bSprains, strains, contusions, and lacerations were disregarded; if any of the former were reported as the most common class of injury, the second most common class of injury has been noted here instead.

^cStudy data taken from 2 sources: AHSA and USPC.

^d15.5% of all injuries (unspecified total) for the AHSA data set; 32% of all injuries for the USPC data set.

^e4.7% of all injuries for the AHSA data set; 0% of all injuries for the USPC data set.

^fCombined musculoskeletal injuries accounted for 64% of total injures.

^g37 extremity fractures, occurring in about half of all patients.

^hExtremity fractures were 18% of observed injuries.

ⁱAmong severe injuries, extremity fracture accounted for 37%.

^jPercentages >100% due to multiple causes of injury reported.

TABLE 3.

Distribution of Fractures (Excluding Cranial as Well as Ear, Nose, and Throat) in Equestrian Injuries

Study	Fracture Distribution, % of Total Fractures Reported (n/N)
	Upper Extremity	Lower Extremity	Spinea	Chest/Torso	Pelvis
Barone and Rodgers2	Both extremities: 41.9 (57/136)		7.4 (10/136)	2.9 (4/136)	3.7 (5/136)
Bond et al6	Both extremities: 77.7 (7/9)		11.1 (1/9)	11.1 (1/9)	0 (0/9)
Carmichael et al7	14.4 (14/97)	58.8 (57/97)	9.3 (9/97)	0 (0/97)	17.5 (17/97)
Ghosh et al15	53.1 (60/113)	23.9 (27/113)	7.1 (8/113)	8.0 (9/113)	8.0 (9/113)
Griffen et al16	31.1 (14/45)	51.1 (23/45)	0	8.9 (4/45)	8.9 (4/45)
Grossman et al17	48.6 (17/35)	25.7 (9/35)	17.1 (6/35)	5.7 (2/35)	2.9 (1/35)
Hobbs et al20	26.5 (9/34)	20.6 (7/34)	20.6 (7/34)	32.4 (11/35)	0 (0/35)
Loder24b	58.1 (796/1371)	16.3 (224/1371)	8.8 (121/1371)c	12.5 (171/1371)d	4.3 (59/1371)e
Press et al30	45.6 (462/1013)	26.9 (272/1013)f	10.6 (107/1013)	12.7 (129/1013)	3.8 (38/1013)
Total	50.7 (1372/2708)g	22.9 (619/2708)	9.4 (269/2853)	11.6 (331/2853)	4.7 (133/2853)

^aIncludes coccyx and sacrum.

^b1 unspecified multiple injury reported.

^cThoracic spine injuries reported under torso injuries.

^dIncludes chest and thoracic spine.

^e94 reported injuries, but those involving sacrum and coccyx counted under spine injury.

^f5 of 1013 fractures unknown.

^gExcludes Barone and Rodgers² and Bond et al⁶ in calculation.

TABLE 4.

Comparison of Fracture Distribution Between Epidemiological Studies in the United States and the United Kingdom

Region of the Body	Fracture Distribution, Mean %		P Valueb
	United States	United Kingdoma
Upper extremity	50.7	57.6c	.190
Lower extremity	22.9	18.5c	.322
Spine + coccyx + sacrum	9.4	5.7	.190
Chest/torso	11.6	8.5	.322
Pelvis	4.7	7.6	.171

^aInformation taken from a set of studies surveying equestrian injury epidemiology in the United Kingdom.^10,27,30,34

^b2-sample z test of means.

^cExcluding data reported by Sandiford et al³¹ due to a lack of differentiation between upper and lower extremity injury.

Discussion

Equestrian events are considered some of the most dangerous, as riding carries the highest risk of mortality among all sports and the risk for major injury is higher than that of motorcycle riding.¹ According to Jagodzinski and DeMuri,¹ 18.7 injuries secondary to equestrian activities are reported for every 100,000 people. Orthopaedic injuries constitute a large portion of these riding injuries as well, accounting for more than 70%, according to Loder.²⁴ Despite these risks, epidemiological studies of injury patterns remain sparse, and reviews of equestrian injury literature are rare.

This review demonstrated that the majority of injuries occur in female riders.¹⁹ Several studies have suggested that this tendency may be due to the greater proportion of female riders compared with males in the US, exceeding 85% in 1 study.^3,19,24 However, as the demographic information of several international studies suggests, this preponderance may not be applicable to other countries, or even to all equestrian sports domestically.^12,22,26 Additionally, Cuenca et al¹³ reported a trend in their review of pediatric rider injuries that boys tended to sustain more severe injuries than girls, which may perhaps be related to a less frequent use of protective headgear.

Our review did not indicate a clear link between the experience level of the rider and risk of injury. Previous studies have reported that riders with less experience are at a higher risk for injury.^13,19,25,28 However, Bixby-Hammett⁴ reported in a study of pediatric equestrians that increased experience is linked to an increase in the number of accidents due to a greater degree of exposure to the sport. Additionally, Grossman et al¹⁷ reported no correlation between rider experience and injury occurrence. Further work is needed to clarify this relationship.

Estimates of injury incidence rates vary widely, and no consensus has emerged in the literature. The most comprehensive estimate to date was performed by the Centers for Disease Control and Prevention on data from 1988 to 1989, which estimated 18.7 injuries per 100,000 riding incidences.²⁰ The lowest estimates of injury incidence were provided by equestrian organizations, with the United States Pony Club reporting 1 accident for every 158,607 hours of all the activities conducted by the organization¹⁶ and the North American Horsemen’s Association reporting only 0.15% of its riders suffering a significant injury per year. The highest injury rate was reported by Costa-Paz et al¹² for polo players, at 7.8 per 1000 game-hours. Complicating the portrait of injury incidence was that different studies used different metrics to quantify injury frequency, from hours of horse-related activity²⁵ to hours riding^1,4,7,9 or number of rides.^2,3,33 Furthermore, no consistent definition of what constitutes an injury has been used in the literature.

Grossman et al¹⁷ observed this variability in 1978 from the range of injury incidence estimates coming out of the UK and Scandinavia.¹⁷ More recently, Havlik¹⁹ attributed the wide range of injury estimates to differences in nationality, geography, specific equestrian activity, the local popularity of the sport, access to care, the likelihood of riders to seek out care for an injury, and study design and data acquisition methodology. Mayberry et al²⁵ indicated that differences between studies may also be attributable to estimation biases. Ultimately, this lack of consensus indicates a need for a more standardized and clearly defined approach to estimating injury incidence in equestrian sports.

All studies reviewed here indicated a fall from a horse to be the leading cause of injury.^1,12,22 Maintaining balance on a horse can often be a challenging task, and while most sporting horses are trained, they are still animals capable of erratic or violent behavior (such as bucking, spooking, or stopping abruptly), which may throw a rider from the saddle and result in severe injury. Proper footwear and riding position can help mitigate this risk, though it is an inherent danger in the sport that cannot be completely avoided.

In this review, fractures or orthopaedic injuries were the most common classes of injury reported in 7 of the 19 US-based studies. Of the injuries reported in this review, the mean number of injuries attributed to fractures in the US was 33.6%.^13,24 Differences in injury rates between riders of different countries have been reported previously.³³ However, there were no national differences in the distribution of fractures across the body between the US and the UK (see Table 4).^10,27,31,34

None of the articles reviewed specified the types of fractures that were encountered for their data series. Areas of incidence for the fractures were provided in 4 studies.^15,17,24,30 While Ghosh et al¹⁵ provided the most detailed account of the distribution of fractures occurring across the body in the patients examined, specific types of fractures were not described. To better characterize orthopaedic injury patterns in equestrian sports, further work will be needed to detail the specific types and frequencies of fractures observed.

Upper extremity fractures accounted for the majority of fractures at 50.7% in the US. This finding is consistent with the studies by Ghosh et al¹⁵ and Loder,²⁴ which found the highest incidence of fractures in the upper extremity. The large prevalence of upper extremity fractures is likely due to impact with the outstretched arm after falling or being thrown from the saddle.^17,19

The role of protective equipment in preventing injuries was not evaluated in this study. However, we did observe that the use of protective equipment varied widely, from 6% to 66.7% in the studies reviewed. Previous reports have focused on the role of headgear in preventing head and facial injury. However, it is difficult to tell whether there was a trend for increased usage of protective headgear over time and whether headgear usage decreased injury occurrence or severity. Chitnavis et al¹⁰ reported a 5-fold decrease in hospital admissions, mostly due to a reduction of head injuries, which was hypothesized to be associated with an increased use of protective headgear. In 2002, Moss et al²⁷ reported a drop in both the incidence and severity of fractures to the skull and attributed this trend to the use of approved safety helmets while riding. Hughes et al²¹ noted that the United States Pony Club has observed a significant decrease in head injuries since the adoption of required helmets in 1990. However, contrary to these 3 studies, Loder,²⁴ working with data cataloged in the NEISS database between 1991 and 2004, found no significant decrease in head injuries at the national level during this time period.

The reviewed data indicate that beyond head or facial trauma, fractures are an important class of injury in equestrian sports and would merit greater consideration as a factor in injury prevention and also in the advocacy for the development or implementation of additional protective equipment. In this review, 17 of 19 studies reported orthopaedic injuries—particularly extremity fractures—to be either the leading or second-most common class of injuries seen in equestrian sports. Yet, to the knowledge of the authors of this study, no current regulation exists for the mandatory implementation of safety equipment designed to protect against extremity fracture. Several authors in the past have advocated for the development of additional protective equipment, notably for the upper extremities, and have demonstrated the benefits of their use in other sports.²⁷ Moss et al²⁷ and Loder²⁴ have suggested the implementation of upper extremity protective equipment inspired by protective standards for rollerblading. Furthermore, a study conducted by Hasler et al¹⁸ found that protective waistcoats in riding helped significantly reduce risk of injury. Additionally, in their epidemiological retrospective study, Whitlock et al³⁴ suggested that the lack of ankle injuries in their study may reflect the increased use of stronger riding boots. While this latter trend may be attributed to other factors such as differences in risk to the lower extremities due to fall patterns when compared with the upper body, protective equipment should still be evaluated for its potential benefits. Especially for areas of the body at high risk for fracture, such as the shoulder, elbow, and wrist, protective equipment may prove beneficial in reducing injury occurrence. Thus, the effect of protective equipment may be an important facet of reducing riding injury and should be investigated further to elucidate the degree of protection offered by its use.

This review has important limitations. More serious injuries such as fractures, dislocations, and head and neck injuries are more likely to be reported in the literature, and less serious soft tissue injuries may be underreported. Fractures, dislocations, and spine injuries are easily diagnosed and reported; however, soft tissue injuries may not be recognized or recorded.

Thus, orthopaedic injuries are likely underestimated in the literature, and they may be more prevalent in equestrian patients than this review suggests. Ultimately, this review is most limited by the scarcity of studies of equestrian-related injury over the past 40 years. However, this limitation also underscores the need for reviews such as this one to pool information across studies and derive valuable information on orthopaedic injuries in equestrian disciplines.

Conclusion

This current concepts review reports the incidence and patterns of orthopaedic injury occurring during equestrian events. Fractures account for 33.6% of all injuries reported in the US, with a majority of these fractures occurring in the upper extremities (50.7%). Most of the injuries occurred in female riders, and injuries were more common in inexperienced nonprofessional athletes. Patterns of injury did not vary between the US and the UK, though more fractures occurred in the US. The role of protective equipment was not reported in these studies; however, given the high incidence of orthopaedic injuries outside of the head and neck, we advocate for the use of protective equipment for the upper and lower limbs in addition to helmets.