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Equestrian injury is commonly seen at trauma centers and the severity of injury is often high. We sought to determine the risk, incidence, and the influence of skill and experience on injury during horse-related activity (HRA).Members of horse clubs and individual equestrians in a three-state region (Oregon, Washington, and Idaho) were recruited via mailings and community advertisements to take a survey regarding their horse contact time and injuries over their entire riding career. Serious injury (SI) was defined by hospitalization, surgery, or long-term disability.There were 679 equestrians with a median age of 44 years who reported a median of 20 hours of HRA per month with a mean of 24 years (1 to 75 years) experience. The cumulative risk of any injury (AI) was 81% and of SI was 21%. The incidence of AI and SI were 1.6 ± 0.1 (SE) and 0.26 ± 0.02 per 10,000 hours, respectively. The incidence, per 10,000 hours, of AI was 7.6 ± 2.7, 2.4 ± 0.2, 1.5 ± 0.1, and 1.0 ± 0.1 at novice, intermediate, advanced, and professional levels, respectively (p < 0.001, analysis of variance [ANOVA]) and of SI was 1.03 ± 0.52, 0.38 ± 0.06, 0.21 ± 0.03, and 0.19 ± 0.04 at the respective skill levels (p < 0.001, ANOVA). There was a sharp decline in incidence of injury between 18 and 100 hours of experience. Helmet use was 74%, 61%, 58%, and 59% at the respective skill levels (NS, χ2).One in five equestrians will be seriously injured during their riding career. Novice riders experienced a three-fold greater incidence of injury over intermediates, a five-fold greater incidence over advanced riders, and nearly eight-fold greater incidence over professional equestrians. Approximately 100 hours of experience are required to achieve a substantial decline in injury. These findings suggest that equestrian injury prevention efforts need more attention and should focus on novice equestrians.