Juan Acosta wears a gnarled knuckle and misaligned collarbone like badges earned during his 16 years racing horses nearly 20,000 times. He also recalls times when he's "seen stars."
"Concussions, I've had maybe five or more," said Acosta, known as J.D., a regular at the Laurel Park racetrack. "You get back on. We're always going to try and be tough."
Jockeys take huge risks for little pay — riding atop horses weighing more than 1,000 pounds running 40 miles per hour. They are independent contractors, responsible for their own health care, and typically paid per race plus a small share of any winnings.
The horse racing industry has long tolerated and even encouraged an ethic of racing battered and bandaged -- but, like football and other sports, the dangers of concussions may be driving a change at the tracks.
Dr. Kelly Ryan, a sports medicine specialist at MedStar Health who works at Maryland's racetracks, contributed extensively to medical protocols recently approved by a national horse racing body for concussions. Such protocols, not yet widely adopted at tracks nationwide, are treatment guidelines for medical personnel and outline when a jockey may ride again after getting a concussion from a head knock or violent tumble.
Ryan and other MedStar doctors had already developed their own protocols while working at Maryland racetracks under MedStar's two-year-old contract with the Maryland Thoroughbred Horsemen's Association, which represents the state's owners and trainers. Partly in response to rising awareness of concussion risks, the horsemen's association hired MedStar to provide both emergency and routine health care to jockeys and other track workers at Laurel Park and Pimlico, the Baltimore home of the Preakness Stakes slated for May 19.
"No one has had protocols for concussions," said Ryan, who is one of four MedStar doctors with clinic hours at Maryland tracks. "And when you're here on a daily basis you see how important they are."
Concussions are traumatic brain injuries that can cause headaches, ear ringing and memory loss. Studies of football players show repetitive head blows have led to chronic traumatic encephalopathy, which kills brain cells and causes aggression, depression or dementia.
Sometimes jockeys just don't feel right as they recover from a blow to the head.
Acosta, who races as many as seven days a week in several states, said Ryan "asks a lot of questions" when someone falls or hits their head. She has grounded five jockeys in two years for concussions, and the jockeys are slowly accepting that they shouldn't always get right back on a horse, he said.
Ryan said she knew nothing about horse racing when she sought a job two years ago in sports medicine at MedStar, but she and others were able to study and modify the protocols used by other sports. They can direct jockeys to stop riding for days or weeks.
The MedStar doctors have conducted baseline physical and cognitive assessments on about 30 regular riders to help them gauge post-injury changes. They collect more limited injury information on dozens of visiting jockeys too, though many aren't certain how many concussions they have suffered.
There is little research on jockey injuries.
A 2009 report by the U.S. Department of Health and Human Services found there were more than 14,000 racing industry-associated injuries among 150,000 backstretch workers and jockeys treated in U.S. emergency rooms and 79 deaths between 1998 and 2006.
Carl G. Mattacola, director of the Jockey-Equestrian Initiative Sports Medicine Research Institute in the University of Kentucky's College of Health Sciences, found that from 2012 to 2015 about 8.6 percent of falls by jockeys resulted in concussions, though the figures are not comprehensive.
The university is two years into a three-year pilot program that could lead to more data. As part of the effort, protocols developed in consultation with Ryan are now used at Kentucky tracks, including Keeneland and Churchill Downs, home of the Kentucky Derby. The aim is to demonstrate a smooth implementation process that could be adopted at all tracks and promote a universal system for maintaining jockeys' medical and injury information.
The protocols would sustain the long-term health of jockeys and the sport itself, Mattacola said.
"This doesn't just provide a standard of care but includes an educational piece too," he said "That will promote the health and welfare of jockeys and equestrians."
Resistance to the new protocols remains at many tracks, which unlike in other sports, operate independently, said Terry Meyocks, national manager of the Jockey's Guild that represents about 1,250 active, retired and disabled jockeys across the country.
Hiring and training staff to identify and manage concussions have costs and logistical barriers, though Meyocks said he believes owners and tracks might save on insurance. He also said jockeys are independent contractors who only get paid to race and may brush off long-term threats to their health. Most jockeys, whose median income is about $27,000 a year, don't typically buy health insurance.
"It's disappointing," Meyocks said. "We've been working on this for years and we've made some progress, but not enough."
In Maryland, David Richardson, executive director of the horsemen's association, agreed that a professional sport should have standards for concussions and health care generally. The group decided sport medicine specialists were warranted for jockeys and backstretch workers.
"It's all kind of logical, but it just hasn't existed," he said. "We're trying to be proactive. The concussion issue has really brought the NFL to its knees."
The track clinic in Laurel is stocked with aspirin, ice packs, orthopedic boots and tetanus shots for those bitten by an animal. But Ryan and other doctors also tend to high blood pressure, diabetes and other chronic conditions.
Diana Pinones staffs the front desk and makes appointments on the more than 170 races days at Maryland tracks. She said the care has been welcomed by many and she often takes calls from workers after hours, and in Spanish.
Richardson declined to say what the MedStar contract costs, but he said it was less than the cost of an in-house doctor who largely cared for injured jockeys on race days.
Former rider Bobby Lillis now works for the Horsemen's Assistance Foundation, part of the horsemen's association that helps jockeys pay for medications or other needs that are not provided. He said routine injury care isn't something he could have imagined when he rode.
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Jockeys fall off horses and bang their heads all the time, he said.
"We used to dust ourselves off and hobble back on the horse," he said one recent Friday. "I'm so glad to see it's better now."
Not long after he mused about injuries, an overzealous horse threw a rider on the way to the starting gate for the day's first race at Laurel. Ryan was in her clinic at the time, which is equipped with TV monitors showing the track. She was alerted by walkie talkie that the jockey landed on his feet and needed no medical attention.
Earlier, she'd checked out the nose of another jockey who was head butted by his horse the day before. She inspected and squeezed the bruised bridge and tried to tape on padding, but it blocked his vision. She decided it was okay to race with goggles directly on his face.
Ryan later noted with a hint of pride, "He just won his race."