It is not often that a physician is able to bring elements of her personal life into her practice, but that is exactly what Dr. Naomi Betesh of Union County Orthopedic Group has done with her program, Saddle Up: A Focus on Equestrian Injury Rehabilitation. The program combines Betesh’s expertise in physical medicine and rehabilitation and pain management with her love of horseback riding. As an avid equestrian, her goal is to treat equestrians with chronic injuries, help injured riders return to riding, as well as prevent future injuries.
Horseback riding is a burgeoning sport with some 30 million Americans participating. These riders range from recreational riders to competitive professionals who travel nationwide for competitions. Like any athlete, equestrians are at risk for injury due to improper mechanics and chronic overuse. “The most common chronic injuries among equestrians are injuries to the neck, shoulders, lower back and hips,” Betesh said. “Also, as many recreational riders continue to ride into their 60s and 70s, they are also at risk for common degenerative conditions that increase in frequency with age. My goal is to help these riders return to riding.” Causes of injury Many lumbar spine injuries can be attributed to improper riding posture coupled with unstable core muscles. “When the core muscles are not functioning optimally, the rider tends to hunch forward — causing the spine to be in a flexed position,” Betesh said. “While in this position, the normal forces absorbed by the intervertebral discs become exaggerated and can lead to disc injuries.” Commonly, these injuries are herniated lumbar discs that can manifest as pain in the lower back, hips and legs. The shoulders and cervical spine also are susceptible to overuse injuries from forces transmitted from contact with the horse’s mouth as riders push and pull on the bit to control the speed and direction of the horse. Osteoarthritis of the hip and knee also are common conditions in the aging rider and can sometimes require total hip or knee replacements. Also, as the rider ages, they are more susceptible to fractures from any type of fall, whether they are on the ground or on a horse, leading to time away from riding. “Injuries are not relegated to only the aging rider. In my practice I have treated riders of all ages.” Betesh said.
Betesh’s approach for treating equestrians involves a multidisciplinary approach including rehabilitative therapy, medications and therapeutic procedures. “Much of the health focus among equestrians is about the horse and not necessarily the rider,” Betesh said. “I wanted to be able to give riders a resource to help them take as good of care of themselves as they do their horses.” Betesh’s is part of the team at Union County Orthopedic Group, with offices located in Linden and Clark.
Dr. Naomi Betesh Launches Effort to Treat and Educate Riders Saddle Up: A Focus On Equestrian Injury Rehabilitation One of the few things that precedes my love of medicine has always been my love for riding. As a teen, I spent weekends at my neighbor’s standardbred horse racing farm where I truly enjoyed the seemingly mundane chores of feeding the horses and cleaning the stalls. Occasionally, if I was really lucky, I would be allowed to ride the one horse on the property that could be ridden. I hacked in a Western saddle and was the happiest girl in the world. Many years later, on vacation, I took my children horseback riding in Colorado. My youngest daughter immediately fell in love, just as I did at her age, and when we returned home riding became her weekend activity. The barn was only 20 minutes from our home and every weekend I sat through every lesson watching enviously. After watching only a few of her lessons, I decided to take lessons too. That was almost 2 years ago. Since then I have been schooling in hunter/ jumper lessons since and recently started dressage. On January 15, 2013, our life was changed forever when we acquired a horse we fell in love with that was abandoned at the barn by another family. I was surprised and elated to find out that her show name was Jersey Girl. My mother reminded me of the times when I was younger and begged her for a horse. I now fulfilled every little girl’s dream and my own. I also convinced my husband to take a few lessons by telling him it was silly to tell people you owned a horse but did not know how to ride. He has been hooked since. Many times around the barn, other riders complained of chronic aches and pains. Other times, I would not see the familiar faces for weeks at a time. When I would ask them where they had been, they would tell me that their back, shoulder or hip pain prevented them from riding for a while. I too, during my riding irritated an old shoulder injury and had to take a little time off. In my office I have treated many equestrians and often no matter how severe the injury, the first question they asked was when can I ride again?
I decided that as a clinician I should make an effort to educate and help these fellow riders. From here, Saddle Up: A Focus On Equestrian Injury Rehabilitation, was developed with the goal of getting equestrians back in the saddle after injury and trying to prevent injury. Common Injuries Back pain is one of the most common complaints among riders and studies have shown a high incidence of back pain in riders. In fact, 30% of all riding related injuries were to the lumbar spine. One of the most important structures in the rider’s body is the spine. While riding, the spine is responsible for absorbing the compressive forces generated by the horse. The incidence of lumbar spine injuries can most often be attributed to improper posture coupled with unstable core muscles. When the core muscles are weak or not functioning optimally the rider tends to hunch forward causing the spine to be in a flexed position. While in this position, the normal forces absorbed the intervertebral discs becomes exaggerated and can lead to disc injuries. For riders, herniated discs often occur over time as a result of the repetitive concussive forces generated by the horse are absorbed by the discs. The cervical spine is also another common area of injury due to repetitive strain and overuse. This is usually a result of forces transmitted from contact with the horse’s mouth. Repetitive strain can also lead to tendonitis in various muscles such as the biceps or injuries such as carpal tunnel. Another common injury I see in my practice among riders is Sacral dysfunction. The sacroiliac joint is responsible for connecting the spine to the pelvis and allows it to remain stable. It is common for riders to have one side that is stronger than the other and this difference in strength can lead to Sacral dysfunction, which can cause one leg to seem longer than the other. If the stirrups are not adjusted for a leg length discrepancy, the rider may tend to shift more weight to the side of the shorter leg causing an unbalanced seat. This lack of balance often can cause accelerated wear on the hips and sacroiliac joint.
Since pelvic alignment is a crucial component of balance in the saddle, it is important for riders to address side to side strength differences and any limitation in pelvic mobility. A key element in avoiding many musculoskeletal injuries is proper core stabilization and training. Most often, this type of training can be done with a physical therapist with knowledge of riding. The therapist will most often set a regimen of workouts designed to strengthen the core muscles thus leading to a reduced risk of injury. For those who are already experiencing pain or other symptoms, it is important to speak to a medical professional as these injuries can worsen if ignored. As we know, riding is an activity not relegated to one singular age group and many continue to ride into the 60’s and 70’s. With the aging rider, there are several factors unrelated to riding that can lead to injury. Osteoarthritis of the hip, knee and shoulder joints and spinal stenosis are prevalent injuries among this age group. The risk of fracture from any kind of fall, whether on the ground or while on the horse, also increases. Fortunately, with advances in modern medicine, surgical techniques and focused rehabilitation therapy under the supervision of a physician who understands riding can prevent the aging rider from spending extended time away from riding. Avoiding Medical Care Sadly, it is all too common for riders to forego seeking medical advice at the onset of pain as most fear the diagnosis will force them to spend time away from doing what they love. This is an all too ironic mindset considering what great care we take of our horses but often not ourselves.
This was exemplified by renowned Grand Prix Dressage Rider, Pam Goodrich. Pam underwent a hip replacement surgery as a result of degenerative arthritis. Pam had been suffering this pain for 15 years but had attempted to stave off any form of surgery as long as possible. It was only when her pain began affecting her ability to compete that she decided to undergo surgery. However, after surgery Pam returned to competition with no weakness or deficits and went on to win another Grand Prix, this time without being in pain. Pam often said she wished she had not waited so long to have this injury properly addressed. Saddle Up: A Focus on Equestrian Injury Rehabilitation My goal with this Saddle Up is not only to treat riders suffering from chronic injuries, but to educate them as well. It is also to help people return to riding after an injury or surgery. Whether you are a weekend rider or an avid competitor there is always the opportunity to improve your riding and avoid injury. With this program I want to be able to afford riders the opportunity to continue doing what they love without sacrificing their physical health. For those who are experiencing pain that is preventing them from enjoying riding, education is key. Finding a physician who is familiar with your needs and lifestyle is one of the most important factors when seeking care. I have been fortunate enough to treat many talented riders and there is no greater satisfaction for me than seeing them get back on the horse after an injury. Dr. Naomi Betesh is board certified in Pain Management and Physical Medicine and Rehabilitation and is part of the team of specialists at Union County Orthopedic Group.
Dr Betesh completed her residency training in Physical Medicine and Rehabilitation at Mount Sinai School of Medicine where she was elected and served as Chief Resident. She then, completed a fellowship in Pain Management in the department of Anesthesiology at Mount Sinai School of Medicine. Dr Betesh’s practice focuses on a multidisciplinary approach to pain including interventional procedures and rehabilitation medicine. If you, or someone you love, is suffering from pain that is preventing them from riding, or to contact her about this program please call 732.388.1761 or visit www.unioncountyortho.com.
Union County, NJ – Horseback riding is one of the fastest growing sports in America with some 30 million participating in the sport. Competitive horseback riding is an extremely diverse sports with children competing as young as 5, and Olympic riders on average in their 40s. Many riders continue to ride recreationally into their 60s and 70s. Whether they are competitive or recreational riders, equestrians must be in peak physical condition. Traditionally, most of the focus has been on the health of the horse and not necessarily the rider themselves. However, equestrians are not immune to many of the chronic conditions that plague athletes of all sports. Sadly, each year thousands of riders are kept from riding due to the pain and disability of these injuries. Common Injuries Among Equestrians Injuries often occur secondary to overuse, muscle imbalance and training deficits.
Low back pain is a common complaint of riders due to the high forces absorbed through the lumbar spine and pelvis when riding. If the spine is not in the proper position while riding the forces are not evenly distributed and are greatly exaggerated, expediting the degenerative process. Herniated discs, sacroiliac dysfunction, spondylolisthesis and facet hypertrophy are common degenerative injuries that can plague riders. The shoulders and cervical spine are also susceptible to overuse injuries from forces transmitted from contact with the horse’s mouth. About Saddle Up As an avid equestrian, Dr. Naomi Betesh has begun focusing on the treatment of equestrians, who have often been an underserved population of athletes. Her medical expertise in pain management and rehabilitation and shared love for the sport will help equestrians treat and prevent injuries. Dr. Betesh’s approach for treating equestrians involves a multidisciplinary approach including rehabilitative therapy, medications and therapeutic procedures, resulting in less time away from the riding due to injury. Dr. Betesh has teamed up with physical therapists to create a rehabilitation program designed specifically to help return injured equestrians to riding and to help correct training deficits to prevent future injuries.
Dr. Betesh is also planning several educational courses in the New Jersey area with the aid of her horse, Jersey Girl. About Dr. Naomi Betesh Dr. Naomi Betesh is board certified in Pain Management and Physical Medicine and Rehabilitation. She is also certified in acupuncture. She is currently part of the team of specialists at Union County Orthopedic Group, located in Linden and Clark, New Jersey. Dr. Betesh completed her residency training in Physical Medicine and Rehabilitation and her fellowship in pain management in Anesthesiology at Mount Sinai School of Medicine. Dr. Betesh’s practice focuses on a multidisciplinary approach to chronic pain including interventional procedures and rehabilitation medicine. Her medical expertise and experience regarding horseback riding injuries has been a major contribution for Union County Orthopedic Group, as well as the community of equestrians in the tri-state area. For more information about this program please contact: Union County Orthopedic Group 908.486.1111
What inspired you to create Saddle up?
Saddle up was started because I realized that while there are many programs geared toward other sports, there is little geared to preventing and treating injuries in equestrians. I would often meet other riders with chronic injuries that were having difficulty returning to riding. Also, other doctors would refer the riders to me as they could not relate to someone with a fracture that could not even walk yet wanted to know if they could start riding again.
Who is the person that inspires you the most and why?
This is a really hard question to answer because I have been inspired by many different people for many different reasons. Some in life in general, some in my medical career and some in my riding career. My mom though, has been a huge inspiration to me. She taught me to be an independent women. Growing up, I was taught that I could do anything if I set my mind to it. Whenever I was frustrated and could not figure out how to accomplish something, she reminded me that if you do not want to do something all you see is the obstacles. If you want to do it, you see the solutions. This reminder always challenged me to find the solution!
What is the greatest thing you learned from your riding career?
I learned a lot about connecting and understanding the horse I am working with so that we can actually work as a team. I learned to let go of my fear and any anxiety I had about trying something new because my horse was able to tell even if no one else could. I learned to be confident in my decisions even if they were not perfect so to expect my horse to follow them and not make decisions on her own.
Why are equestrians unique when compared to other athletes?
While the average age of equestrians competing in the Olympics is close to 40, in 2012 the Japan’s Hiroshi Hoketsu competed in the London Olympics in Dressage at age 71. Overall the average age of all Olympians competing in 2012 was 26. Riders are unique because they continue to ride well into their 60s and 70s. This puts riders at risk for common degenerative conditions that increase with age.
Why do equestrians often “ride through the pain”?
Equestrians often ride through the pain because they love to ride. Often they are training for a show or taking lessons and do not want to cancel them. Also if they own or lease a horse, someone has to exercise it so they ignore the pain.
Also, riders are often frustrated by the lack of knowledgeable practitioners that treat equestrians. No one wants to be told that they need to take time off from riding especially when they are not given any information about when they can return and how to prevent deconditioning while away from riding.
I started riding again at the age of forty two. I rode as a child at a friend’s farm but never took formal lessons. My, then twelve year old, daughter started taking lessons and after watching her I decided to start too. In the beginning I expected everything to hurt after riding. When I started to learn how to canter, hurt was not the word for the pain I felt the day after riding. Even after taking four ibuprofen and two acetaminophen, I still had pretty bad pain. My co-workers could not understand why someone would continue to do something that hurt so much. How could they possibly understand? They’re not equestrians. While my instructor tried with great effort to teach me to canter properly, it was only later on that I learned what I was doing wrong and was able to correct it. In hindsight, there were ways I could have helped prevent injury to my back and I was lucky that a few days of rest was all I needed to get back to riding. In my office I see many equestrians that have to stop riding for months to treat a back injury. Whether it occurred on or off a horse, is irrelevant. What is relevant is that it limited their ability to ride and in some cases was aggravated by riding without addressing the problem.
More than 30% of riders will get low back pain at some point in their career according to studies. I believe the number is a lot higher than that. If you think of your back, especially the discs and small joints, called facets, as shock absorbers you can easily imagine how the forces transmitted from poor positioning can take a toll on your back. You have a good instructor, and you are trying as best you can to be in the correct position and yet your back still seems to be taking a pounding when you ride.
There are things that you can do on and off the horse to help strengthen your body and prevent injury. Take time focusing on strengthening your core which includes your abdomen, pelvis, and low back. If one part of your core is weak, the other areas will tend to do more of the work. For most people, the abdomen is the weakest link in the core. Frequently, people are unable to do sit ups so they think they are unable to strengthen their abdominal muscles. However, there are many ways to strengthen abdominal muscles. Cross training on days when you are not riding by doing Yoga or Pilates focusing on core work, can go a long way to helping prevent injury.
When you ride, focus on engaging your core. I encourage my patients to engage their core, no matter what type of sport they are involved in. The hardest part of engaging your core is knowing how to do so. When you cough or laugh, your core naturally engages. You can mimic these movements to see what it feels like to engage your core properly.
Around the barn, pay attention to your positioning when you are caring for horses. People tend to remember that shoveling snow can hurt your back if you do not use proper positioning. The same is true for shoveling manure. It is important to choose a lightweight, ergonomically designed shovel. Take breaks frequently. Do not bend from the waist when shoveling. Squat with a straight back and use your leg muscles to lift.
It is all too common for riders to delay seeking medical advice for fear that they will be told that they will have to stop riding for a while. Often this delay, actually leads to a worsening injury requiring more treatment. It is important to get a diagnosis prior to treatment. Pain is a symptom of an underlying problem. Treating the pain without figuring out what is causing it, is like finding a leak in a dam and covering it with a bandage. It is important to see a physician and have your problem diagnosed before seeking treatment.
Dr. Betesh and her horse, Jersey Girl
Dr. Naomi Betesh is board certified in pain management and physical medicine and rehabilitation. She is also certified in acupuncture. She practices in Clark and Linden, New Jersey. She created Saddle Up: A Focus On Equestrian Injury Rehabilitation, was developed with the goal of getting equestrians back in the saddle after injury and trying to prevent injury