There have been very few studies looking into the epidemiology of sports injuries, and in particular sports head injuries (SHI) within a rural location. Head injury is a significant cause of resultant disability in young people, and is the major cause of death in those under 45 years who suffer an injury of any kind. In view of this we aimed to investigate the epidemiology of SHI in the rural Scottish Borders and the demands placed upon the department as a result. This was a retrospective study looking at all patients attending the Emergency Department (ED) of the Borders General Hospital (BGH) over a 4-month period with a head injury sustained during a sporting event. Over this period, 51 individuals presented to the BGH ED with a SHI. SHI accounted for 15% of all head injury presentations during this period and occurred most frequently in those aged 10–15 years participating in rugby, horse riding or mountain biking. The incidence of injury was higher for males with a male:female ratio of 3.3:1. Significant demands placed upon the ED included imaging of 45% of these patients and admission of 31% of patients attending with a SHI. Sports are a frequent cause of head injury in this rural population and contribute significantly to the workload of the ED. This is an important health matter as they are one of the leading causes of disability within young people. Three specific sports contributed to the majority of the injuries. This may be due to specific mountain bike centres such as Glentress and Innerleithen as well as the popularity of rugby and horse riding within the borders area.