Horseback riding is an increasingly popular activity among today's youth, providing them with the opportunity to learn responsibility and respect for animals. However, it can also be associated with severe injury, of which many physicians are unaware. In 2002, there were an estimated 13,400 emergency department visits nationwide for horse-related injuries among children younger than 15 years. When using a severity score to compare it with other childhood injuries, equestrian-related injury ranked second only to pedestrians being struck by a car, and had a higher score than all terrain vehicle, bicycle, and passenger motor vehicle crash injuries. Most serious injuries occur when a rider is thrown from a horse, which is often accompanied by being dragged or crushed by the horse. However, hoof kick injuries to an unmounted child represent about 30% of horse-related injuries and may result in more severe injury. Head injury is the injury most likely to result in hospitalization or death. The effectiveness of helmets in preventing serious head injury in horse-related accidents has been very well established. Recommendations for the prevention of horse-related injury include requiring helmet use on and near a horse, use of safety stirrups to prevent drag injury, matching rider skill with the appropriate horse, and providing close adult supervision.