Racehorse injuries

Racehorse injuries and fatalities are a side effect of training and competition. In 2008, Peter Pan Stakes winner Casino Drive got a stone bruise while walking on Belmont Park's horse paths the week before the Belmont Stakes.[1]

The big problem with equine injuries is that they so often result in death.[2][3] A 2005 study by the United States Department of Agriculture found that injuries are the second leading cause of death in horses, second only to old age.[4] Nureyev's recovery from a broken leg while retired at stud in 1987 typifies the struggle horses have after being injured.[5]

Two years after Secretariat's recordbreaking US Triple Crown took the sport to a new level of popularity, the breakdown and death of Ruffian brought on a new era of safety concerns. Racehorses had been breaking down for centuries, but never before in an event so widely seen as the great match race between Ruffian and Foolish Pleasure at Belmont Park with 18 million viewers.[6] The horse racing industry has been trying to adapt to the increased safety concerns ever since. "I personally think that in a very real way, we're almost held to a higher standard because of the horses — they don't make the decision to do this. And I think that's fair," said Nick Nicholson, the president and chief executive of Keeneland.[7]

Classification

The racing industry will always be faced with the unavoidable and inevitable accident when horses get bumped or tangled in traffic, trip, or take a bad step. 1885 Kentucky Derby winner Joe Cotton had to be euthanized after breaking his leg while tripping over two other horses who had fallen in front of him in an 1888 race.[8] Accidents and disputes were so bad in 1732 England, soon after nobility first started racing Thoroughbreds, that participants were ending up in court.[9] The "Sport of Kings" has been described as an exercise in controlled chaos. The jockeys can be daredevils, and the racehorses can be unpredictable.[10] As a response to the chaos, stewardship of racing began to evolve in 1751 when the first set of recorded racing rules were printed and in 1752 when Britain's Jockey Club started to become racing's first regulatory authority.[9][11]

Injuries, unlike accidents, do not happen by chance. The science of injury prevention has demonstrated that injuries and the events leading up to injuries are not random. Like disease, they follow a distinct pattern. Studying these patterns has made it possible to learn to predict and prevent injuries from occurring. Injuries, whether unintentional or intentional, can be considered any physical damage or harm caused to the body resulting in impairment or destruction of health. Injuries lead to death, disability, and financial loss.[12] In 1990, apprentice jockey Benny Narvaez was paralyzed from the chest down after his horse threw him while jumping over another horse who had broken down directly in front of him during a race at Tampa Bay Downs. A jury found that Tampa Bay Downs was responsible for Narvaez's injury because the track veterinarian failed to perform an adequate pre-race examination on the horse that broke down.[13]

International Thoroughbred Fatality Rates

National television coverage of the Breeders' Cup by NBC helped generate millions in revenue and publicity for Thoroughbred racing in the mid to late 1980s. Since the inaugural running of the event in 1984, though, there has been an injury in virtually every Cup renewal. That national publicity backfired when horse racing increasingly came under attack from animal rights groups in the early 1990s. In the 1990 Breeders' Cup Distaff, champion two-year-old and three-year-old filly Go for Wand got back up after breaking her ankle and crossed the finish line on three legs.[6] Then, in the 1992 Breeders' Cup Sprint, the five-year-old European horse Mr Brooks fractured his cannon bone and fell on top of his jockey, Lester Piggott. Piggott had told fellow European jockey Walter Swinburn before the race that the horse did not warm up well. Mr Brooks had also been reluctant to go in the starting gate before the race.[14] There was so much controversy over the handling of Mr Brooks that the Breeders' Cup implemented rigid pre-race inspections in 1993.[15] The resulting media pressure from the deaths of Go for Wand and Mr Brooks prompted racing industries around the world to make a concerted effort at determining the extent of the problem and the causes.[16]

Country
 Fatal Injury Rate*
 Time Period
Hong Kong 0.70 1993-1994[17]
Australia 0.89 1988-1995[18]
South Africa 1.40 1988-1993[19]
United States 1.60 1992[19]
Great Britain 2.28 1990-1999[20]
Japan 3.20 1985-1994[19]

* Rate statistics are based on occurrences per 1,000 starts.

As evidenced by the death of 2006 Kentucky Derby winner Barbaro, not all racehorse fatalities are the direct result of injury. It wasn't the break in Barbaro's leg that necessitated his destruction, but the hoof disease laminitis.[21] Barbaro's team of doctors, led by Dr. Dean Richardson, were able to repair his broken leg, but not the excruciatingly painful laminitis that followed. Support limb laminitis, which is the specific type Barbaro had, is caused by over-stressing the good leg during recovery from an injury in the opposite limb.[22][23] A 1986 survey done by the Morris Animal Foundation found that laminitis was the fourth leading cause of death among horses.[24] AAEP members ranked laminitis as the most important disease needing further research in 2009.[25]

After the death of Barbaro in 2006, the North American Thoroughbred industry realized that individual studies weren't adequate tools for evaluating ongoing efforts in injury prevention.[26] The idea for an equine injury database came from the first Welfare and Safety of the Racehorse Summit in 2006. The database has three objectives: 1) to identify the frequency, type, and outcome of horse racing injuries using a standardized format that will generate valid composite statistics; 2) identify markers for horses at increased risk of injury; and 3) to serve as a data source for research directed at improving safety and preventing injuries.[27] The Equine Injury Database (EID) was launched in 2008 following a one-year pilot project where injury reports were submitted by racetracks in a hard copy form. InCompass Solutions, Inc. and The Jockey Club Technology Services, Inc., subsidiaries of The Jockey Club, underwrote the costs of the Database.[28]

Country
 Fatal Injury Rate
 Time Period
U.S./Canada 2.00 2009-2010[29]

At a rate of 2.00 fatalities per 1,000 starts, two Thoroughbred racehorses die (on average) every day in North America. That incidence rate is also higher than it was in 1992, when it was 1.60 fatalities per 1,000 starts. Neither of those rates include training fatalities. In states that track training fatalities, training accounts for nearly a third of the total fatalities.[30][31] That would mean three Thoroughbred racehorses die every day from training and racing combined.

Biological Systems & Associated Injuries

Injuries are a consequence of demand exceeding the capacity of the tissues and structures of the biological systems.[32] The musculoskeletal system is by far the most commonly injured system.

System
 % of Fatal Injuries
 % of Non-Fatal Career Ending Injuries (NFCEI)
Musculoskeletal 97% ~81%
Respiratory 1% ~10%
Integumentary 1% ~2%
Cardiovascular 1%

[33]

Musculoskeletal system

The musculoskeletal system consists of the bones, cartilage, muscles, ligaments, and tendons.[34]

Skeletal fractures account for 87% of fatal injuries. When a horse’s leg hits the ground at racing speed on a straightaway, it bears a load that is three times its weight (with the exception of harness racing). When negotiating a turn, centrifugal force increases the load to between 5 and 10 times body weight. When a horse hits the ground, the repetitive impact produces microscopic cracks and crevices inside bone so tiny they are undetectable by standard X-rays. If the horse isn't given enough time for healthy bone tissue to repair the damage with a process called remodeling, the cumulative stress can progress silently to the point where overload causes bones to break.[35] The American Association of Equine Practitioners (AAEP) recommends a period of rest of at least 10 days between races for all horses to provide an opportunity to refresh and diminish the volume of persistent cyclic loading.[36]

Bucked shins is an inflammatory condition of the cannon bones. Bucked shins is a result of strain and excessive concussion to the cannon bone. The concussion comes from the rigorous training regimen that 2-year-olds often face and inability of the bone to adapt fast enough. 70% of young Thoroughbred racehorses in training develop the problem, usually in the first six months. As horses become older, the cannon bone becomes stiffer and thus bucked shins rarely occur again. Approximately 12% of horses that develop bucked shins go on to have stress or saucer fractures later.[37] Bucked shins force 7% of racehorses to retire.[38]

Splints are new bone formation (exostoses) along the involved splint bone.[39] In the young horse the interosseous ligament which attaches the splint bones to the cannon can become damaged or torn from the concussive and rotational forces of exercise. This will cause heat, pain and swelling in the area between the splint and the cannon. In an attempt to stabilise this damaged attachment, new bone will be laid down around the ligament resulting in the formation of a bony lump known as a splint.[40] The size and position of this bony lump determine whether a splint is likely to cause long-term lameness. The lump can interfere with the knee joint or the suspensory ligament, which runs down the back of the cannon bone.[41] Splints force 7% of racehorses to retire.[38]

Luxations are joint dislocations and account for 8% of fatal injuries. Fetlock luxations account for 91% of all fatal luxation injuries. Due to the construction of the fetlock joint, luxation will result in either a complete rupture of the flexor tendons and suspensory ligament or a lateral disarticulation. The joint capsule may also be completely ruptured and the articular portion of the bones exposed to view.[42]

An osselet is inflammation (arthritis) of the metacarpophalangeal joint (fetlock) of the equine front leg.[43] Osselets are a result of trauma, such as hard, heavy, or fast use, a slip or fall, or a direct blow to the joint.[44] When the fetlock suffers trauma, enzymes and other agents from the joint lining are released that destroy tissue inside the joint.[45] As the condition worsens, so does the horse's lameness, and the interior structures of the joints become more and more irritated.[43] Osselets force 16% of racehorses to retire.[38]

Carpitis is inflammation (arthritis) of the carpal joint (knee). Carpitis is caused by overextension of the carpus.[46] Knee injuries, the second most common non-fatal career-ending injury, force 16% of racehorses to retire.[38]

A ruptured tendon usually refers to the complete separation of a tendon. Tendon separation results in a complete loss of the tendon fibers, a marked increase in tendon cross-sectional area, and loss of support in the limb.[47] A totally ruptured superficial digital flexor tendon (SDFT) will cause a visible drop in the angle of the fetlock.[48] Catastrophic ruptured tendons account for as much as 3% of all tendon injuries.[49]

Tendinitis is inflammation of a tendon. Tendons connect muscles to bone and normally have an elastic property so that they can stretch. Tendinitis occurs when the tendon is overstretched or overloaded, which causes straining (tearing) of individual or multiple fibers and the formation of a lesion.[50] A lesion is strained tendon fibers with associated hemorrhage (bleeding) and edema (fluid retention).[51] Often strained tendons go undetected or may be subclinical before the clinical signs of tendonitis are observed.[52] Tendinitis is characterized by heat, swelling, and pain. Racehorses often experience tendinitis when transitioning from sedentary activity to conditioning work. Thus young horses and those returning to exercise from lay-off are those most expected to suffer from tendinitis.[53] The incidence of tendon injuries is approximately 30% among Thoroughbred racehorses in training, mostly in the SDFT of the forelimbs.[54] Horsemen frequently refer to tendonitis as bowed tendon due to the bowed appearance of the SDFT.[55] Bowed tendons force 25% of racehorses to retire and are the most common non-fatal career-ending injury.[38] Racehorses are so often retired after tendinitis because as many as 70% will not be able to return to their previous level of performance and more than 66% of them will have a recurrence of injury.[56][57]

Tendinosis is chronic degeneration of a tendon without inflammation. It is caused by repetitive microtrauma and aging.[58] Tendinosis is characterized by painful thickening and structural changes of the tendon.[59] Tendinosis predisposes horses for Tendinitis and catastrophic ruptured tendons.[56][60]

Desmitis is inflammation of a ligament. Ligaments connect bone to bone and, depending on individual function, are either compliant or noncompliant.[61] Ligaments have less elasticity than tendons and can therefore be injured easily.[62] Desmitis occurs most often when a horse overstrides, which causes a sprain (tear).[63][64] Some occurrences of Desmitis may be difficult to detect because the ligament is deep within tissue. An injury to the collateral ligament of the fetlock predisposes the horse to fetlock luxation, the second most common fatal injury.[65][66]

Respiratory system

The equine respiratory system consists of the nostrils, pharynx (throat), larynx (voice box), trachea (windpipe), diaphragm, and lungs.

Exercise induced pulmonary hemorrhage (EIPH) is bleeding in the lungs. There are many theories regarding the causes of EIPH. The most widely accepted theory is that the high blood pressure from heavy exercise coupled with vacuum-like effects that occur during a deep inhalation causes the capillaries to rupture.[67] The prevalence of EIPH varies with the method used to detect it and the frequency with which horses are examined. Almost all Thoroughbred racehorses in active training have some degree of EIPH, as many as 93% according to The Merck Veterinary Manual. When examined after each of three races, 87% of Standardbred racehorses had evidence of EIPH on at least one occasion. That suggests that EIPH is as common in Standardbred racehorses as it is in Thoroughbred racehorses. Higher degrees of EIPH undoubtedly result in poor performance and, on rare occasions, death.[68]

Epistaxis is EIPH characterized by blood appearing at the nostrils. Epistaxis is observed in approximately 5% of horses with EIPH.[69] There are slight differences in the definition of a "bleeder" in various racing jurisdictions throughout the world. Some jurisdictions define bleeding as the appearance of blood at both nostrils, while other jurisdictions only require the appearance of blood at one nostril.[70] There are also various regulations for each incident of bleeding throughout the world.[71]

Country
 1st Incident
 2nd Incident
 3rd Incident
Australia 3 mo. ban retirement
South Africa 3 mo. ban 6 mo. ban retirement
Hong Kong 3 mo. ban 3 mo. ban or retirement retirement
Japan 1 mo. ban 2 mo. ban 3 mo. ban
Great Britain none none none
United States none none none

[72]

Integumentary System

The integumentary system consists of the skin, hooves, hair, and glands.[73]

Hoof cracks are separations or breaks in the wall of a hoof. The most common type of hoof cracks are quarter cracks, which occur at the quarter, the thinnest and most delicate part of the hoof wall. Injury to the site may be the result of common things such as hard racetracks and uneven surfaces.[74] Quarter cracks originate from the coronet and run down the hoof wall, rather than a sand crack that begins at the ground surface and runs up the hoof wall.[75] Hoof cracks force 2% of racehorses to retire.[38]

Risk Factors

The international community has identified important risk factors for injury or fatality in horse racing. These include: horse-related risk factors such as age, gender, and breeding; management-related risk factors such as training, medication, stewardship, economics, and jockeys; race-related factors such as type (flat or jump), distance, and field size; and track-related factors such as weather, surface, maintenance, and design.[76][77][78][79] Injury, in particular catastrophic injury, is a multi‐factorial event that involves the complex interaction of a number of risk factors. The effect of each individual factor and its importance can be measured by evaluating its relative risk.

Factor
 Category
 Rate
 Relative Risk
Race Type Jump 8.30 18.86
Flat 0.44
Medication USA 1.74 3.95
AUS 0.44
Training Low 4.11 1.81
High 2.27
Temperature Cold 3.16 1.67
Hot 1.90
Surface Dirt 2.14 1.38
AWT 1.55
Turf Moisture Dry 2.48 1.38
Wet 1.80
Dirt Moisture Wet 4.42 1.22
Dry 3.63

Race Related

Type

Jumps racing has long been steeped in controversy due to its high mortality rate. This brand of racing requires Thoroughbred horses to leap over a succession of fences and are generally run over longer distances. There are both hurdles (generally shorter with lower obstacles), and steeplechases (generally longer with higher obstacles). Animal welfare groups have been campaigning for around 30 years to abolish hurdle and steeplechase events in Australia. Many aspects to the sport pose serious risk to horses, and it harms horses at a rate far above that of flat racing. In 1991, an Australian Senate Select Committee address on animal welfare concluded they had serious concerns about the welfare of horses in jumps races and recommended that state governments across the country phase out jumps racing over a three-year period. New South Wales and Tasmania abandoned the sport in 1997 and 2008 respectively, but Victoria and South Australia continue.[80] Jumps racing has never been the massive industry in Australia that it is in Britain and Ireland, but even there some tracks have discontinued National Hunt racing.[81] Nottingham was the first to discontinue jumps racing in 1996, followed by Windsor in 1998 and Wolverhampton in 2002.[82] Lingfield and Kempton have considered discontinuing jumps racing as well.[83]

Type
 Fatal Injury Rate
 Fatal Injuries
 Starts
Flat 0.44 316 719,695
Jump 8.30 198 23,857

[79]

Management Related

Training

Catastrophic injuries are often the acute manifestation of a more chronic process.[84] Tissues with the greatest blood supply respond most quickly to conditioning. The first tissues to respond are the horse’s heart and lungs, then his muscles, and last are tendons and bones.[85] The heart, lungs and muscles possess an excellent blood supply. Ligaments, tendons and joint capsules are relatively poorly supplied with blood and strengthening them can take two to four times as long. Bones and hooves require the longest period of time to develop their full density and strength.[86] A British study showed that 78% of fractures occur during training. The substantial proportion of fractures that occurred during training emphasised the importance of studying these injuries away from the racecourse and the large number of stress injuries suggested that training regimes for young Thoroughbreds could be improved to create a more robust skeleton, able to withstand injury and fatality.[87]

The Thoroughbred Owners and Breeders Association (TOBA) statistics on racing related career ending injuries show that high grade races have a much lower rate of injury than low grade races.[88] While this could be attributed to many factors, including the quality of the horse, economics, or medications, the trainer still must make the decision to run a horse or not to run a horse. Because leading trainers consistently get the best horses, injury rates by race grade should correspond to injury rates by trainer. John Gaines even said that trainers are so important, transcendent trainers like Ben Jones, Hirsch Jacobs, Woody Stephens, Bob Baffert, and Wayne Lukas are worth as much as a great stallion or a great broodmare.[89] High grade races are considered stakes, allowance, and maiden special weight races. Low grade races are considered claiming and maiden claiming races.

Race Grade
 Career Ending Injury Rate
 Career Ending Injuries
 Starts
High 2.27 553 243,854
Low 4.11 2,566 624,265

Medication

Dan Hartman, Chair of Racing Commissioners International (RCI), said in March 2011 that a five-year phase out of drugs and medication is reasonable to bring North American racing policies in line with what is going on in other parts of the world like Europe and Hong Kong. Hartman said that a phased approach would give horsemen and owners sufficient time to adjust to the change. Hartman went on to say that he thinks that the regulators are the only voice in North American racing for the horse.[90] RCI was originally called National Association of State Racing Commissioners and consists of mainly North American regulators whose goal is uniform rules and practices and reciprocity in enforcing each member's official rulings.[91] Feeling no pain, an injured horse on drugs may continue to charge down the track, endangering every horse and jockey in the race. Drugs may account for the fact that the North American fatality rate on turf is higher than it is in Australia on turf, or even Great Britain (0.38), where race day medications are not allowed.[92]

Country
 Fatal Injury Rate
 Fatal Injuries
 Starts
AUS 0.44 316 719,695
USA 1.74 134† 77,003†

[79][93]

Track Related

Dr. Michael Peterson of the University of Maine states that there are three components that affect a racetrack's performance as it relates to injuries: the surface of the track, weather, and maintenance.[94]

Surface

In Thoroughbred racing there are three main track surfaces: dirt, turf, and synthetic. Dirt tracks are generally a mixture of sand, silt, and clay. Turf tracks are usually Bermuda grass in warm climates and a mixture of Fescue, Bluegrass, and Rye in more temperate climates. Synthetic tracks are generally a mixture of sand, synthetic fibers, rubber and wax. Synthetics are differentiated by brand names such as Polytrack, Tapeta Footings and Cushion Track.

North American racing is run on all three types of tracks and provides the best basis for a comparison on how track composition affects injuries and fatalities. The EID was finally able to provide statistics on racing related fatalities in March 2010.[27] The TOBA leaked statistics on racing related career ending injuries three months later in June.[88] The EID was able to supplement its March data with a release of a second year of statistics in December. Dr. Tim Parkin, a veterinarian and epidemiologist from the University of Glasgow who has been involved in the EID for more than a year, said that the addition of a second year of information enabled them to statistically validate the data.[93] Not included in EID or TOBA statistics are training or non-race injuries.[95]

The following tables show that the prevalence of Thoroughbred fatalities or career-ending injuries is greater on dirt tracks than it is on either turf or synthetic tracks.

2009-2010 EID Stats

Surface
 Fatal Injury Rate
 Fatal Injuries
 Starts
Dirt 2.14 1,179† 551,100†
Turf 1.74 134† 77,003†
Synthetic 1.55 197† 126,829†
TOTALS 2.00 1,510 754,932

† Approximations based on standard distribution of races per surface.

2008-2009 TOBA Stats

Surface
 Career Ending Injury Rate
 Career Ending Injuries
 Starts
Dirt 3.99 2,711 680,093
Turf 2.37 239 100,796
Synthetic 2.19 247 112,718
TOTALS 3.58 3,197 893,607

Weather

For both dirt and turf surfaces there is a need to understand the relationship between the water content and the surface performance. For these surfaces moisture is the single most important variable in the maintenance of the surface. As synthetic surfaces wear it is also likely that the sensitivity to moisture will increase as the wax coating is lost from the surface.[96]

The TOBA statistics on racing related career ending injuries show that moisture has the opposite effect on dirt and turf tracks. Moisture causes more injuries on dirt tracks, while it reduces injuries on turf tracks.[88] This table does not include data from tracks rated "Good" because that term applies to both dirt and turf.

2008-2009 TOBA Stats

Surface
 Condition
 Career Ending Injury Rate
 Career Ending Injuries
 Starts
Dirt Dry 3.63 2,415 664,944
Dirt Wet 4.42 399 90,324
Turf Dry 2.48 203 81,969
Turf Wet 1.80 11 6,098

Moisture can cause even bigger problems when combined with freezing temperatures. At Philadelphia Park Racetrack in Bensalem, a rash of breakdowns in the first two months of 2004 was blamed on the winter weather and track problems caused by thawing frost. In that short stretch of time, 12 horses were euthanized following races, and another one was destroyed after sustaining a training injury.[97] The TOBA statistics on racing related career ending injuries show that cold weather racing causes almost twice as many injuries as warm weather racing (February's rate of 3.16 is 1.67 times larger than July's rate of 1.90).[88] This graph is a plot of injury rates for different tracks based on when their racing seasons begin and end during the calendar year. To eliminate as many conflicting variables as possible, only North American tracks in temperate climates that race on dirt/turf and that run graded stakes races were used. The tracks were Aqueduct, Belmont, Churchill Downs, Colonial Downs, Hawthorne, Laurel Park, Monmouth, and Saratoga.

Career Ending Injury Rates from 2008-2009 for major temperate climate racetracks.

Without better data, it is difficult to determine the effect moisture and freezing temperatures have on synthetic tracks. Golden Gate Fields has a relatively high career-ending injury rate for a synthetic track and their racing season takes place during winter months, but the coldest temperatures average about 50 degrees Fahrenheit (18 degrees above freezing) in that part of California during that time of year. In Great Britain the fatal injury rate on turf is less than it is on synthetics, which is opposite of North American racing.[98] Freezing temperatures could be the reason because winter racing on the flat only takes place on synthetic tracks in Great Britain. That could result in an increase of the fatality rate on synthetics, but not turf.[99] This anecdotal evidence seems to indicate that synthetic tracks are negatively affected by moisture and freezing temperatures just like dirt and turf.

Maintenance

Current evidence indicates that consistency of each surface and limited variability among surfaces seen by each horse are more important than the exact values of each property. Consistency allows for the horse to adapt through training.[96] Weather and the amount of traffic on a track make consistent surfaces difficult. One of the biggest challenges with a dirt track is that you can design a dirt track for a particular moisture content, but you can’t do it for all moisture contents. In the case of synthetic tracks, wax and polymers used in them will change over time, as will the length of the fibers as they break down from use. The sand in various areas of the track also wears differently.[100] The oils in synthetic tracks also tend to seep into the base of the surface over time, which may explain why some synthetic tracks have not performed as well in their third or fourth years as they did in their first years.[101] The Racing Surfaces Testing Laboratory is working to collect data from racetracks and correlate it with injury rates. Such information will allow track maintenance personnel to make the best decisions for any variable.

Horse-related

Breeding

There has been a lot of debate since 2006 about how sound the Thoroughbred is today compared to the 1960s and earlier.[78][102] The only real data even remotely pertaining to the subject involves the average number of starts per horse, which The Jockey Club started tracking in 1950.[103]

Year
 Avg. Starts
 Starts
 Runners
2010 6.11 417,192 68,235
2000 7.10 493,682 69,569
1990 7.94 712,494 89,716
1980 9.21 593,849 64,506
1970 10.22 488,326 47,778
1960 11.31 337,060 29,798
1950 10.91 244,343 22,388

[104]

Those who argue the Thoroughbred is unsound also point to the fact that horse races are run over shorter distances today. Monmouth Park Racetrack general manager Bob Kulina said long distance races disappeared across America because not enough horses entered to race.[105] A prime example of a race that reduced its distance to keep drawing horses is the Jockey Club Gold Cup.

Year
 Distance
2010 1.25 Miles
2000 1.25 Miles
1990 1.25 Miles
1980 1.50 Miles
1970 2.00 Miles
1960 2.00 Miles
1950 2.00 Miles

Horse conformation, which is a visible outcome of breeding practices, clearly plays a significant role in injury.

References

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