Concussion in Female Riders: Why Recovery Can Take Longer

New research shows women can be out of sport for longer after a concussion. Scientists are still working out why, and the answer seems to involve both the female brain and the care women receive.

Most riders know the routine after a fall: brush off, check the horse, get back on if nothing is broken. A run of recent studies looks at what happens when the head is involved, and at why women can take longer to return.

How riders hit their heads

In eventing, a "rotational fall" has a specific meaning. The horse hits a fence and somersaults, often landing on or near the rider. Researchers at the University of Kentucky have described rotational falls as "the leading cause of death and serious injury in the equestrian sport of eventing."

Most concussions in female riders come from far more ordinary falls, and those are what helmet researchers have been studying.

Researchers at University College Dublin and the University of Ottawa, led by J. Michio Clark, reconstructed 25 real falls that caused concussion and 25 that did not, using video from horse racing and eventing cross-country. Their results were published in the Journal of Science and Medicine in Sport in 2020. In the falls that caused concussion, riders' heads struck turf or sand at an angle.

An angled impact makes the head spin as well as stop. Biomechanics researchers call this rotational acceleration, and it strains brain tissue. The Dublin group proposed concussion risk levels for riders covering both linear and rotational motion.

In a follow-up study in the Annals of Biomedical Engineering, the same team found that helmets significantly reduced rotational motion and strain in the brain during angled falls. Even so, helmeted falls still produced forces consistent with concussion. The authors wrote that "scope exists to improve the capacity of equestrian helmets."

Traditional helmet standards test a straight drop onto a steel anvil. The Virginia Tech Helmet Lab's equestrian ratings, first released in December 2022, also account for rotational acceleration and the surfaces riders actually land on. "Standards for equestrian helmets are typically based on severe impacts," said Stefan Duma of the Virginia Tech Helmet Lab. Many riders fall at lower speeds, and the lab found many helmets were too stiff to cushion those softer impacts well.

Symptoms that arrive late

Delayed symptoms are common in other sports. Nobody has yet studied whether angled impacts in riding falls make them more likely.

A University of Manitoba study of 144 young athletes, published in Frontiers in Neurology in 2020, found that one in six had symptoms that started at least 15 minutes after the injury. The typical delay was about an hour, and for some it was many hours. Athletes whose symptoms started late were less likely to be removed from play straight away.

In a Curtin University study of 232 adults, published in PLOS One and announced on 7 October, 45.6 percent still had symptoms a year after concussion. Losing consciousness or needing a CT scan did not predict who would struggle. Severe symptoms in the first days did, making lasting symptoms nearly three times as likely.

"That tells us it's not always the injury that appears most serious at the time that leads to the poorest recovery," said lead author Dr Jacinta Thorne of the Curtin Medical Research Institute.

Pre-existing sleep disorders made lasting symptoms 5.1 times more likely, and a history of mental health conditions 2.6 times more likely. People hurt outside organized sport were 2.5 times more likely to have lasting symptoms, and Thorne noted those injuries are often linked to events such as falls. The study did not look at riders, but a rider who comes off on a quiet hack, alone, sits closer to that group than to an athlete with a medic on the sideline.

Women out for longer

At the University of Limerick, Dr Ian Kenny and Professor Tom Comyns analized six seasons of grassroots rugby injury records covering 5,740 players. Their findings were published in Sports Health and reported in mid-October. Of the female players who were concussed, 46 percent were out for more than 28 days. Among men, the figure was 30 percent. The study did not set out to explain the gap.

Researchers have looked at two broad explanations: differences in the female brain and body, and differences in the care women receive. Neither has been ruled out, and no study found clinicians keeping women out longer simply as a precaution.

Thinner fibers, hormones and necks: impacting concussion in female riders

In 2017, researchers at the University of Pennsylvania reported in Experimental Neurology that female axons, the long nerve fibers that carry signals through the brain, tended to be smaller and to have fewer microtubules. Microtubules are the internal tracks that move material along the fiber. When the team stretched axons in the lab to mimic injury, the female axons' microtubules were more likely to break, and they showed more damage a day later.

"The paper shows us that there is a fundamental, anatomical difference between male and female axons," said senior author Dr Douglas Smith, director of the Penn Center for Brain Injury and Repair. The work was done on cells and computer models, and the researchers said studies in people are still needed.

A 2013 study in the Journal of Head Trauma Rehabilitation followed 144 women treated in emergency departments for mild brain injury. Women injured in the second half of their menstrual cycle, when progesterone is high, reported poorer health a month later than women injured in the first half or women taking oral contraceptives.

Then there is the neck. A 2019 Rutgers University review in the Journal of Orthopaedic and Sports Physical Therapyfound that a stronger neck may reduce the force passed to the brain during an impact. "Women typically have less neck strength and experience a greater concussion risk," said senior author Carrie Esopenko.

Who gets seen, and how fast

When women and men get similar medical care, the gap often shrinks. A 2021 study from the NCAA and US Department of Defense CARE Consortium, published in the British Journal of Sports Medicine, compared 1,071 concussions in matched men's and women's college sports. Overall, there was no significant difference in time to return to play. Women recovered more slowly in contact sports and at smaller colleges with fewer sports medicine resources.

A larger CARE analysis, published in Sports Medicine in 2024, followed 906 athletes in 15 sports played by both sexes. Women and men recovered along the same path on tests of thinking, balance, symptoms and mental health. "Historically, some women's sports didn't have the same on-site access to health care," said senior author Jaclyn Caccese of Ohio State University. Women did start return-to-play workouts about a day later on average, but both sexes were back to full competition at about the same time.

Access to care makes a difference. A 2023 study in the Journal of Athletic Training found that male high school athletes were more often checked on the field by an athletic trainer than female athletes, at 40 percent compared with 32 percent. A 2024 study in Brain Injury found that the longer it took to diagnose a concussion, the longer recovery took.

The CARE researchers also found that women reported more symptoms than men, both before injury and during recovery. They could not tell whether that reflects biology or differences in how men and women report symptoms.

Feeding the injured brain

After a serious brain injury, the body enters a state of high energy demand and muscle breakdown. A 2020 review in Frontiers in Neuroscience described how this drives the high-protein feeding plans used in neurological intensive care. A 2011 Institute of Medicine report on nutrition and traumatic brain injury called for feeding to start within 24 hours of a severe injury.

That same report described early research into creatine and omega-3 fatty acids as promising but unproven. For milder injuries such as sport concussion, the evidence is not well researched. In a 2024 study in Nutrients, researchers at Atlantic Technological University in Galway interviewed 17 performance dietitians. Many used protein, omega-3s or creatine with concussed athletes, but one summed up the evidence as "no real hard and fast evidence on it."

Riding is one of the few sports where women make up most of the participants. According to US Equestrian, 85 percent of its members are female.

It is also a leading source of serious head injury. A University of California, San Francisco study published in Neurosurgical Focus in 2016 looked at adults treated at US trauma centers for sports-related brain injuries between 2003 and 2012. Equestrian sports accounted for 45.2 percent of them, more than any other sport.

None of the recovery studies in this article looked at riders. They followed rugby players, college athletes and patients in emergency departments. How women recover from concussions sustained in the saddle has not yet been studied in the same way.

This article is for information only and is not medical advice.