Riding Dressage After Injury

A New Jersey physician and horsewoman helps her patients return to riding after an injury.

Like other athletes, equestrians must cope with the physical problems that often crop up while they are pursuing their sport. But many physicians don’t understand what riding entails and therefore cannot give good guidance about when and how to get back in the saddle after an injury. However, if a patient at the Union County Orthopedic Group in New Jersey asks, “When can I start riding again?” her physician is ready with a response: “We’re going to send you to Dr. Betesh.”

Ankle stretches can be done on the stairs at your home or on the mounting block as you’re warming up for your ride. (Credit: Nancy Jaffer)

Naomi Betesh, DO, a member of the practice, understands the patient’s concerns because she, too, is involved with horses. A casual rider in her youth, the mother of three went back to the sport three years ago at age 42, when she started taking lessons and bought her own mount. Her involvement has led to a broader understanding of equestrians’ ailments. “Part of being able to rehab is knowing when you can go back to your life,” observes the doctor.

Working with riders came naturally, since Betesh was already doing rehabilitation and pain management, treating people with back pain, sacroiliitis, neck pain and other injuries, all of which are common to riders. “I realized after talking to people in the barn that a lot of them either had chronic injuries and didn’t know how to deal with them or weren’t riding because of them,” she says.

The doctor saw a need for people to learn how to prevent injuries and rehab the chronic conditions they have, which led her to start a program called “Saddle Up Equestrian Injury Rehabilitation” (

Common Rider Injuries

The incidence of lumbar-spine injuries in riders most often can be attributed to improper posture coupled with unstable core muscles. The core muscles include pelvic, abdominal and lower-back muscles that allow the body to remain upright and keep the spine in a proper position. Thirty percent of all riding injuries are related to the lumbar spine and that number is even higher among competitive riders.

When the core muscles are not functioning at their optimum, the rider tends to hunch forward, causing the spine to be in a flexed position. In this position, the normal forces absorbed by the intervertebral discs become exaggerated and can lead to disc injuries. Most commonly, these injuries are herniated lumbar discs, causing pain in the lower back, hips and legs. Herniated discs can also cause burning, numbness or tingling in the lower extremities. In equestrians, herniated discs often occur as a result of the repetitive concussive forces generated by the horse, which are absorbed by the spinal discs. Small micro-ruptures begin to weaken the discs. That eventually causes the gelatinous fluid of the disc to protrude into the spinal canal or irritate the spinal nerves. Herniated discs can make riding especially painful because the pain tends to intensify with activity.

Since a large amount of the communication between rider and horse occurs through the seat, lower-back pain is a common complaint. Overuse injuries in the lower back usually have an insidious onset of pain, but riders often seek treatment only when they are in too much pain to ride or the pain affects their performance.

Using a multidisciplinary and non-surgical approach, Saddle Up Rehab is geared not only to helping alleviate pain, but also to preventing injuries. Riders are encouraged to work on strengthening their core and correcting training errors such as riding lopsided or leaning forward or backward too much, which puts a lot of pressure on the back.

The Importance of Exercise

An exercise ball has many uses for a rider, from upper-body work to pelvic tilts and perfecting balance. (Credit: Nancy Jaffer)

A rider’s fitness level is important for a number of reasons. Even dismounted, riders still face plenty of opportunities for hurting themselves. “Everything’s connected,” says Betesh. “If your abdominal muscles are weak, you’ll use your back or hips more and over-compensate by using your knees. We see a lot of shoulder wear and tear from what goes on in the barn and some elbow tendinitis, too.” 

Betesh points out that it’s important for riders to build endurance. “Once you get tired, you tend to go back to old habits and muscle memory and then you start to compensate,” she says. “For instance, if my core is weak, I can still remember to engage it the first time I go over a jump. But after the fifth time, things start to fall apart. When people are tired, they tend to make more training errors.”

Betesh does exercises every day and recommends that her patients do the same, but cautions riders not to get overwhelmed. “If a busy schedule means you can’t work out for a half hour, I tell patients the benefits are cumulative. If you can find five or 10 minutes to work out and make it into a habit every day or at least every other day, it adds up.”

She says on the days a patient isn’t riding, it would be good to do some type of aerobic exercise. The goal is five days of exercise a week. So if you’re riding three days a week, you might consider aerobic exercise on the other two days. It could be swimming, brisk walking, cycling, an exercise video or a workout that varies high intensity and recovery periods.

Stretching is also important. Betesh does 10 minutes daily and often adds core strengthening to the mix. She particularly likes planks, lunges, squats, hip openers and yoga exercises such as downward dog and cobra. She suggests that a new rider do ankle stretches, placing the ball of the foot on the lower level of a set of stairs while holding on to a handrail for balance and dropping the heel as if it were in a stirrup. She also recommends stretching after a shower because the body is warm then or after going for a walk as a way to warm up. “The key thing is you have to work with your routine,” she says. “Once I get to the barn, I’m busy getting the horse ready and focusing on her needs. For me, the routine works better at the house.”

While she likes yoga and Pilates, Betesh notes, “It’s important if you’re a beginner that you go to a class and don’t try to follow directions from a video on your own at first because it looks simple. Without having someone to correct the way you do it, you don’t know if you’re doing it properly and easily can get injured.” She also advises using common sense when trying these exercises. “We have patients who are injured doing yoga and Pilates because they push things a little harder than they should. Everybody in their class was standing on their heads because they have been doing it for 20 years, so they decide to stand on their head, too, even though they’re not ready for that level of expertise.”

Returning to the Saddle

Nancy Conner follows Dr. Naomi Betesh’s advice for standing on a stool to put away a saddle on a high rack in the tack room. (Credit: Nancy Jaffer)

It’s important to be realistic when discussing getting back on the horse after an injury, but eager riders often abandon common sense. “If you come in and say, ‘I’m in pain and I can’t go to the store and I can’t work,’ we’re not talking about horseback riding,” says Betesh. “You need to be able to do your daily functions without pain before you’re ready to get back on.”

Betesh also notes that when it’s time to ride again, “You can’t just go back to where you were. You need to take a step back when you get on again. That may mean getting on a different horse or it may mean walking and trotting on your own horse for just five minutes before calling it a day. Don’t hesitate to have a professional prepare the horse for you, which may include longeing the horse, as you start back to riding. The trainer can assess the horse’s level of energy and prepare him to the point where he is ready for a rehabbing rider to get on.”

Meanwhile, a rider needs to assess her level of fitness and experience and not run the risk of going beyond what her body can handle. “It’s really important to work on proper form before you jump higher or go beyond your comfort level in dressage,” says Betesh. “You’re much more prone to injury if your form isn’t right.”

If you’ve had problems with your horse, she points out, it’s time to assess him in relation to yourself. “One important thing for people to realize is when the horse is not the right match for them. Especially as you get older, you need to make sure that horse matches your ability. We’re not as strong as we were when we were 15 and we don’t bounce as well either.”

Even if you do have the right horse, you need to make sure your strength, ability, fitness and balance match his. An older horse who seems safe but is at a far higher energy level than his rider may end up pulling while being led, for instance, and a rider who either doesn’t know how to deal with that or lacks the strength to do so could sustain shoulder problems as a result. 

In the big picture, Betesh cautions, “It’s important to know when you do have an injury, when to stop riding or when to cut back on what you’re doing.”

Simple Tips for Injury Prevention 

• Stand on a stool when putting a saddle on your horse or when putting it away on an elevated rack in the tack room. Holding something heavy when your arms are raised risks injury because that’s a weak position, in contrast to doing it with arms parallel to the ground. 

• Look at your equipment and take note of how heavy it can be as a subtle reminder to be careful when moving it.

• Mount using a mounting block. If you get a leg up or mount from the ground, you may end up using your shoulders to boost yourself.

• Instead of carrying full water buckets, use a wheelbarrow or fill empty buckets with a hose while they’re hanging in the stall.

Helmet Safety

I don’t understand why someone rides without a helmet,” says Dr. Naomi Betesh. At the same time, she warns, “Helmets don’t protect from all brain injuries. Sometimes people think, ‘I’m wearing a helmet,’ so they do things they wouldn’t otherwise do.”

Betesh, who is board-certified in traumatic brain injury, emphasizes, “When you have a fall, you do not have the judgment to decide whether to get back on your horse. You are not in a position to make that decision. It is better to stay on the ground and be checked out. Studies with children show that a second concussion within a certain amount of time is cumulative. You can wind up with a worse brain injury even if you had two small concussions.”

The brain needs a chance to heal after a head injury. “If you are diagnosed with a concussion while at a show, don’t stay to watch,” says Betesh. “Go home or to your hotel and rest.”

Although the thought of discarding a $500 helmet is upsetting, it’s important to remember that if you hit your head while you are wearing a helmet, it needs to be changed or inspected. Some manufacturers will examine the helmet for you to see if it’s all right. Some also will offer a discount on a new helmet.

Dr. Naomi Betesh (pictured riding Allegria) focuses on a multidisciplinary approach to chronic pain, including interventional procedures, acupuncture, electrodiagnosis and rehabilitation medicine. She is board-certified in physical medicine, rehabilitation, pain management and traumatic brain injury and is certified in acupuncture. A graduate of New York College of Osteopathic Medicine, she was inducted into the National Osteopathic Honor Society. After completing a preliminary medicine internship at the Mt. Sinai School of Medicine/Elmhurst Hospital, where she was named Intern of the Year, Betesh completed her residency training in physical medicine and rehabilitation at Mt. Sinai School of Medicine, where she was elected chief resident. After her residency, Betesh completed a fellowship in pain management in the anesthesiology department at the Mt. Sinai School of Medicine. She is a partner in the Union County Orthopedic Group in Union County, New Jersey (






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