Common, mostly mild, and it usually settlesEmerging evidence
Back pain is common in riders. In 347 Portuguese federation riders, 61.7% had low back pain in the past 12 months, women and men alike, and it went with riding 7 or more hours a week, riding for a living and daily stable duties. A review of 14 studies of 4,527 riders found that 27.9% to 87.9% had it at any one time, but only 6 studies were high quality, and the authors warn that "the overall low quality of studies limited the comparability of findings". In 886 Italian competitive riders, 74.2% had had low back pain in a year, and in 2,049 US riders, 27.5% reported long-term back pain.
Most of it is mild to moderate. In 508 German competitive riders, 72.5% reported back pain, with an average of about 4 out of 10 whatever the discipline, and "A significant correlation between the intensity of riding or the riding discipline and frequency or severity of back pain could not be found". In 353 young female show jumpers, most had "minimal disability" (65.7% to 81.7% by group). These are surveys: they show how common pain is, not that riding causes it. The NHS says back pain "usually improves within a few weeks".
Sources 1, 2, 3, 4, 5, 6, 7
Your back absorbs the horse's movement, most in sitting trotEmerging evidence
In collected (sitting) trot, 7 elite riders' lower backs arched and then reversed with each diagonal step as the pelvis followed the saddle. In 21 dressage riders, loading at the lower back rose "in all planes in the order walk < rising trot < canter < sitting trot"; in 12 riders, peak pelvic accelerations were 5.52 against 0.85 m/s² in canter against walk; and in 13 riders, "Peak acceleration of the sacrum, C7, and head decreased as the stirrup length was shortened in the standing phase of the rising trot" (the sacrum is the base of the spine, and C7 the bony point at the base of the neck). Strength and core endurance didn't relate to the jolts, so the authors suggest technique training. Professionals kept the pelvis "closer to the mid-position and further forward" than beginners.
None of these studies measured pain. They show where the load goes, not that sitting trot causes back pain, and in 100 South African dressage riders, more hours of sitting trot weren't linked to more back pain.
Sources 8, 9, 10, 11, 12, 13
The saddle, the stirrups and sitting evenlyEmerging evidence
In 108 UK riders, 66% of those on general-purpose saddles had low back pain against 23% on deep-seated or western saddles, with "a possible tendency for there to be more low back pain among riders using a short stirrup length". It's an old, small survey, riders who choose different saddles differ in other ways, and its stirrup finding points the other way from the jolt study above, so neither settles the question. In 8 rider and horse pairs, "even small saddle changes affect the pair's biomechanics", including the rider's pelvis.
Nearly every rider sits a little unevenly: on a riding model, 99.3% put more weight through one stirrup than the other when sitting, and higher-level dressage riders showed small left-right differences in posture. Whether this causes back pain hasn't been tested.
Sources 14, 15, 16, 17
The upper back, neck and shouldersEmerging evidence
In 331 international event riders, 96% had competed in pain, and 76% placed it "in the neck, upper back or shoulders"; in 50 elite dressage riders, 76% placed it in the low back. Both are small, self-selected surveys at single competitions.
Sources 18, 19
Yard work countsEmerging evidence
Mucking out, lifting and carrying add their own load. In a survey of 800 Swedish riding instructors, past-year symptoms were commonest in the shoulders (60%), lower back (56%) and neck (52%), and "Removal of manure from the stable was considered to be the task involving the heaviest work". Video analysis of stable work found that mucking out, bedding and sweeping "involved over 60% work postures where the back was bent, twisted, or both bent and twisted", and the riskiest steps used long-handled tools or the wheelbarrow. In 352 British racing staff, low back pain was one of the commonest complaints and went with 10 to 11-hour days, and Portuguese riders who did daily stable duties had more back pain.
Sources 20, 21, 22, 23, 1
Falls, kicks and crushes: uncommon, but where the serious injuries come fromEmerging evidence
In Swedish federation insurance claims, "87% of the injuries occurred while riding, 9% during horse-handling and 2% while mounting/dismounting", and falls caused 84%; in US emergency departments, most injuries while mounted came from "a fall or being thrown (73.9%)" and most unmounted ones from kicks. Spinal injuries are a minority of riding injuries: 14% of injuries at a Swiss trauma centre and about 10% of riding fractures in Sweden's fracture register. A UK review found that "Head injuries outnumber spinal injuries by five to one", and that "In contrast to other sporting accidents, there are more lumbar and thoracic than cervical injuries": more in the lower and middle back than the neck.
In a Dutch series, "The majority of the fractures (78%) are seen at the thoracolumbar junction Th11-L2", where the upper and lower back meet, and every patient was free of nerve damage. In US emergency departments, riding spinal fractures were in the lower back (49.1%), the upper and middle back (24.4%), the sacrum and tailbone (15.5%) and the neck (11.0%), and "Neurologic injury was rare (1.8%)". In New South Wales there were two spinal cord injuries in 21 years among federation riders and none in the Pony Club. Spinal fractures became more common with age at a Swedish trauma centre, and injury rates rose 139.6% in riders over 60 in US emergency data.
Sources 24, 25, 26, 27, 28, 29, 30, 31, 32
The tailboneEmerging evidence
No riding study of tailbone pain was found. The NHS lists "an injury or accident, such as a fall onto your coccyx" among the common causes, along with strain from long spells of sitting, as when driving or cycling. About 1 in 7 riding spinal fractures in US emergency data were of the sacrum or tailbone, and these were the least often admitted to hospital (33.5%).
Sources 33, 30
When a scan or test mattersStrong evidence
Most riders' back pain needs no scan: the National Institute for Health and Care Excellence (NICE) advises against routine imaging. In 58 elite riders and 30 people who didn't ride, 88% of the riders had a history of low back pain against 33%, but their magnetic resonance imaging (MRI) scans didn't explain it: "there is no conclusive MRI evidence to suggest that the cause lies in undue disk degeneration, spondylolysis, spondylolisthesis, or pathologic changes of the paraspinal muscles of the lumbar spine". Disc changes are common in people without pain.
A scan matters after a fall with pain in one spot over the spine, for anyone from 50 or with thin bones after a fall, with leg weakness or the cauda equina signs, and after a kick or crush to the trunk. Riding fractures were mostly compression fractures where the upper and lower back meet.
Sources 34, 35, 36, 29
How it usually goesEmerging evidence
Ordinary back pain eases within weeks: in people with a new episode, average pain fell from 52 to 23 out of 100 in 6 weeks, and NHS inform says new or flared back problems "should begin to settle within 6 weeks". In German competitive riders with back pain, 61.6% of dressage riders and 40.9% of show jumpers said riding improved it, and for riders who already had back pain, riding at walk "seems to have a positive influence on pain intensity".
After a riding spinal fracture, Dutch patients' average back disability score 7.3 years later was 5.5 out of 24 (low), though 22% had lasting limits at work; in a German series, 9 of 24 people stopped riding after a spinal fracture. No one can promise a date.
Sources 37, 38, 5, 29, 39
When it isn't riding: the causes the warning signs cover
Some back pain has causes riding didn't create, and the warning signs follow the pages behind them. Numbness around the genitals or bottom, new bladder or bowel trouble or both legs weak can be cauda equina syndrome, a 999 call in the words of the NHS back pain and sciatica pages. After a fall, the NHS falls page says to call 999 if someone may have hurt their head, neck, back or hip, and the NHS head injury page's 999 list includes a knock to the head with a fall from more than 1 metre. British Equestrian's concussion guidelines list red flags such as neck pain and weakness or tingling in the limbs, and say not to move the rider or take off their riding hat unless you're trained, unless they're having difficulty breathing. NHS inform's neck injury page and the NHS whiplash page say which neck symptoms need help the same day.
A kick or a crush can hurt the ribs or what lies under them: the NHS broken ribs page says to call 999 or go to A&E for worsening breathlessness or chest pain, pain in your tummy or shoulder, or coughing up blood, and at a Scottish hospital, riders who were kicked or crushed had more injuries to organs in the tummy than those who fell. The NHS osteoporosis page says to call 999 or go to A&E for severe pain after a fall or injury. A sore lump between the buttocks can be an infected pilonidal sinus, which the NHS pilonidal sinus page describes as pain and swelling at the top of the cleft of the buttocks, sometimes with a pus-filled abscess, and back pain with a fever, after cancer, or with weight loss or night pain is rare; the back hub's lines say what to do.
The other warning signs follow the pages they were first written from. A burst abdominal aortic aneurysm (a swelling of the body's main artery) can cause sudden, severe tummy or back pain, a 999 call on the NHS aneurysm page; the NHS kidney infection page says when back or side pain with a very high or very low temperature needs an urgent GP appointment; and the NHS foot drop page covers difficulty lifting the front of the foot. A Leicestershire NHS leg pain leaflet lists the leg symptoms that need a GP or NHS 111 urgently, such as leg weakness that is getting worse; NICE's guideline on spinal metastases covers new back pain in people who have or have had cancer; and NICE's spondyloarthritis guideline sets out the inflammatory back pain features that mean a referral to a rheumatologist. A hot, swollen joint can be septic arthritis, and the NHS septic arthritis page lists a high temperature, "although not everyone has one".
After a fall, NICE's spinal injury guideline lists the dangerous ways to hurt the neck that put someone at high risk, among them a fall from more than 1 metre or 5 steps, a dive and a horse riding accident. Small spinal fractures from thin bones are described on the Royal Osteoporosis Society's symptoms page and the US orthopaedic surgeons' OrthoInfo page, and the UK osteoporosis guideline (NOGG) and NICE's osteoporosis guideline cover how they are found and who needs a bone check; an Essex NHS trust's leaflet says that if broken fragments press on the nerves and the legs become weak, "we need to see you urgently". In a study that followed 500 children from the age of 6, a stress fracture in the spine (spondylolysis) was found in 4.4% at 6 and 6% in adulthood, its slip rarely got worse after the teenage years, and 45 years on, those who had one did about as well as other people. In pregnancy, the NHS back pain in pregnancy page says to contact your GP or midwife urgently for back pain in the second or third trimester, which could be a sign of early labour, or back pain with a fever, bleeding from the vagina or pain when you pee.
Sources 7, 40, 41, 42, 33, 63, 64, 65, 66, 67, 68, 87, 70, 71, 73, 72, 74, 83, 75, 69, 76, 77, 78, 79, 80, 81, 82, 86
