Is Pickleball Causing More Injuries?
The score will soon be forgotten but the friends you make playing pickleball will be yours forever.
- Bryan Klepper M.D.Orthopedic Surgeon and Pickleball Pioneer
Is Pickleball Causing More Injuries?
Pickleball is the fastest growing sport in the United States with 36 million people of all ages playing. As an orthopedic surgeon, I am frequently asked if I am seeing an abundance of pickleball injuries.
A quick search of healthcare costs related to pickleball will estimate the burden to our healthcare system being between 400-600 million dollars. I would argue that these numbers may serve as a catchy headline, but it’s nearly impossible to predict the true cost.
So yes, I am seeing pickleball injuries, but no more than any other common sport. As with many other sports, most of these injuries are preventable with some preparation. Have I noticed the sport being a boom for business? Well, it doesn’t quite stand out like other sports or events. Ice storms and snow certainly cause more of an increase in business. When I started my practice, Heelys (the shoes kids wore with the skate wheel in the heel) kept me busy.
People also like to ask about CrossFit, but CrossFit has never been a problem. Most people who sign up for CrossFit are already athletic, so injuries are not that much of an issue. A bigger problem I saw was “CrossFit light” where people who were looking for a way to get in shape signed up for CrossFit type classes, and got injured trying modified CrossFit exercises since they hadn’t built up their fitness level.
Pickleball is similar. People who already exercise regularly or fit people of any age can enjoy pickleball with minimal risk of injury, but as with any activity it’s never risk free.
What is Pickleball?
So, what is this sport with such a strange name? I had never heard of it until a group of four men started playing in my community - indoors with a removable net and lines. What confused me was how two very fit brothers in their 50s were competing with two relatively fit 70 year olds, one who had at least one knee replaced (at the time I was unaware that the older pair would soon win the state championship for their age category). It was hard for me to imagine how this was a good match up, but that is the beauty of pickleball. It’s a sport athletes that all ages can enjoy.
How to Play Pickleball
Pickleball can be played indoors or outdoors on a court half the size of a tennis court with a small paddle-like racquet and a wiffle ball. It can be played singles (1v1), but is usually played doubles (2v2). The first two shots of each point are like tennis and the rest of the point is somewhat like ping-pong. It’s an easy game to play.
You play to 11 and only score when you are serving. Losing 11-0 is the dreaded ‘Pickle’, but even when pickled there are usually fun, exciting points. I’ve seen players almost pickled who then pickled their opponent the next game. Most pickleball players seem to enjoy the social aspect, and are eager to teach the game to beginners. As a multi generational sport it’s a fun activity for parents and children and even grandparents and grandchildren. In a community, pickleball is a great way for multiple generations to become aquainted.
If you have played racquet sports like tennis, squash, paddle, or racquetball you can pick up the game easily and are likely to be somewhat competitive from day one. If you have never played racquet sports you can still have fun on the first day, but being fit and having good hand eye coordination will certainly give you an advantage. The ability to move quickly helps, but speed and strength play little role in the outcome of a game.
The funny thing about pickleball is that all players will be humbled. You will lose to players who look like they can barely walk. On the other hand, an experienced player can lose to an athletic beginner who gets on a roll. Regardless, players of different abilities can still have fun together.
Since the ball moves slower than tennis, getting overpowered is not much of an issue. Rarely do you whiff or miss the ball completely like a beginner does in tennis. When you hit the ball out of bounds it doesn’t miss by a mile like in tennis, so most misses were almost good shots.
Common Pickleball Injuries
Tennis Elbow
Tennis elbow or lateral epicondylitis can happen in pickleball. It is tendinitis or partial tears of the forearm tendons where they attach on the outer part of the elbow. Contrary to the name, most patients I see with tennis elbow don’t actually get the injury from tennis. A co-resident during my sports medicine training was a former professional tennis player and he believed real tennis players don’t get tennis elbow. If people get it from playing tennis it’s the result of a poorly executed backhand swing.
Stretching and technique can prevent tennis elbow from happening. A correct backhand is a full swing with the elbow slightly bent, similar to a baseball swing. A common mistake that beginner pickleball players make is bending their elbow to 90 degrees and then extending it fully as they hit the ball. If outer elbow pain starts to occur, early treatment is beneficial (see Lateral Epicondylitis in the diagnosis section for more info).
Tennis players should be cautious. I treated an avid tennis player, who in the middle of her tournament tennis season, developed a bad case of tennis elbow from playing a social game of pickleball. Tennis elbow heals without injections or surgery 98% of the time, but it can be frustrating and recovery takes patience. A moment to practice a proper backhand can make all the difference.
Tendonitis & Rotator Cuff Partial Tears
Tendonitis and partial tears of the rotator cuff tendons are common in asymptomatic patients. Older patients will often have full tears without having pain. However, movements involved in pickleball can easily aggravate these previously asymptomatic tendons. The majority of pickleball shots are below the waist, and as a result overhead shots are far less common. In tennis, you have frequent overhead shots including the serve which means your shoulder stays warm and loose. In pickleball, you may go several games without an overhead swing. If you don’t prioritize stretching, and have a habit of powering through your overhead then you're at risk for injury. If you have a history of shoulder issues, stretch before playing and focus on positioning instead of power to decrease the chance of injury. Consider taking a few minutes a few days per week to maintain healthy shoulders. (for more information read Shoulder Impingement in the diagnosis section and Physical Therapy-Shoulder in the weekly blogs)
Back Strains
With frequent low shots, back strains can be common. Taller players will need to frequently bend down to hit the ball. As with all activities, bending at the knees is best, but a flexible back and strong core is beneficial. Stretching before and after playing is necessary if you find yourself prone to low back issues. I’ve frequently stated that everyone should be doing routine back therapy and this includes pickleball players.( for more info go to back pain in the diagnosis section and Physical Therapy-Back Pain in the weekly blogs)
Achilles Tendon Injuries & Calf Strains
These are not uncommon in pickleball. A strain can recover quickly, but an achilles rupture will require prolonged immobilization or surgery. This injury can occur in any middle aged or older athlete. You can dramatically decrease your risk by stretching before a game. You will frequently hear me reminding my friends before any sport to stretch their achilles. (For more information go to Foot and Ankle in the diagnosis section or Physical Therapy- Foot and Ankle in the weekly blogs)
Common Sports Injuries
Other pickleball injuries include those that are common in any sport. A twisted knee can result in collateral ligament, meniscus, and cruciate ligament sprains and tears. A twisted ankle can result in an ankle sprain or an ankle fracture. Jumping or falling on a tight knee can result in a patellar or quadricep tendon tear. A slip or twist and fall can result in wrist fractures or fractures of other body parts.
Many of these can be prevented with a little pre-season balance and agility work in less active individuals.
Pre-Existing Injuries
Finally, many injuries are simply aggravations of pre-existing injuries in older players. Many seniors who have knee arthritis or shoulder tears need routine home therapy to keep playing. Some need an occasional medication or injection to keep going if the joint is aggravated.
No need to warm up, we’re not getting any better!
-Daniel Baird “the worlds most average pickleball player”
For kids, teenagers, and young adults pickleball is extremely safe. Middle aged players are where the injuries often occur. Pickleball is somewhat of an explosive sport even though it requires far less speed or jumping than other sports like basketball, soccer, lacrosse, and tennis. Middle aged players will frequently walk on the court and just start playing. This could result in a devastating achilles rupture or a frustrating tendonitis or back strain.
A common trait between people in this group is that they often still consider themselves competitive athletes. When they start losing to a hobbled older player they will try to make up for it with athleticism. That is a fool's errand. More often than not the well placed shot will beat the athletic shot that may put you in position for injury.
Older players tend to be wiser and many are retired tennis players. They often shuffle to prevent injury and play smart rather than aggressively. They position themselves on the court and place their shots to remain competitive. Most importantly they will concede challenging shots so they can continue to play long term.
Fortunately we have not had many injuries. With Seniors we are constantly reminding players to avoid falls. No running backwards. I worry about the 45-55 year olds who try to run down every shot and end up falling in the process. We older players realize it’s just better to say “good shot” rather than trying to chase down balls we most likely won’t get to. That way we live to play another day.
- Bruce Hook co-chairman community Pickleball committee
Injury Prevention
Pickleball is often a social sport where you rotate partners and opponents after each game. This means you may play a game, sit out, and play again. In this case, it is wise to stay loose and stretch before heading back on the court. Another word of caution. I am aware of one previous middle aged men's happy hour group that would drink beer or sip whiskey between games. They seem to drink in moderation, but just remember some liquid courage does not make you bulletproof.
Now, I mentioned some believe that pickleball can be a costly hobby for our health care system. The biggest injury I have seen to date happened to my own mother. In her early 30s, she tore a meniscus in her knee playing tennis. In the old days, they just took the whole thing out which helped, but it inevitably led to arthritis. She remained active playing tennis until her late 50s, but gave it up due to knee arthritis. She continued to walk and play golf, and as her friends joined the pickleball craze she held off to protect her knee.
Eventually, conservative care failed and in her late 70s she had a knee replacement. With a new knee she decided to play pickleball, and on her first shot she took one step back and broke her hip. After emergent surgery by Dr. Paul King of Annapolis, she made a full recovery and is walking a good distance for exercise now at the age 85.
I learned an important lesson from her experience. Someone who retires from a sport like tennis, soccer, or basketball can likely head directly to the pickleball court. Someone like my mom who is athletic, but avoided sports for many years should take some time to build their strength back up. If you fall into this category, I recommend strength and agility training prior to even practicing. A fall risk assessment and bone density screening is also helpful.
The Benefits Outweigh the Potential Cost
My mother is an example of an extreme pickleball injury, but the benefits of the game far outweigh the risk. I believe that keeping middle aged and seniors healthy will actually decrease medical costs in the future.
For every injury, there are likely far more players who are starting strength and conditioning programs so they can continue to play. Others are concentrating on stretching and nutrition to improve their games. The sport will build agility and maintain bone strength in seniors and decrease off the court injuries. It is a safer outlet for middle aged players rather than playing a few more seasons of a more aggressive sport. The social aspect and the focus required will keep our seniors sharp and engaged as they age. The sense of community will improve everyone’s mental health. This is really important for seniors, but also extremely valuable for young players to connect with their elders. Pickleball is the fastest growing sport in America, and we are better for it.
About Dr. House
Dr. House has been practicing orthopedics for over 20 years. He plays pickleball occasionally and most often during a Friday night happy hour group. He lives in a small community outside of Annapolis, Maryland that recently built 4 pickleball courts. Pickleball is a noisy sport and many neighbors do not appreciate the sound. Some tennis players do not want pickleball ball lines on the tennis courts. After a short civil war between tennis players/neighbors and pickleball advocates the community built courts further away from the community homes thanks to generous donations. Everyone is happy again. This is an avid tennis community where every child grows up playing tennis in summer camp so the majority of pickleball players are retired or former tennis players. Most young and middle aged players continue to play both. Building courts has made this close-knit community even closer. Players of all ages play together. The seniors turn on the lights and start playing at dawn throughout the year, the middle agers play after work, and the kids play under the lights late into the evening.