Pickleball Primer: An Overview of Common Injuries, Treatment, and Optimization Strategies in Pickleball Athlete

Pickleball is a popular sport with players of all ages, fitness levels, and experience. Few medical providers are familiar with this relatively new sport. There is sparse research on the most seen injuries, treatment considerations, and return-to-play recommendations. The goals of this review are to (1) familiarize the orthopaedic surgeon with the basic rules and physical activities required to play pickleball to counsel patients on their suitability to play, (2) report on the most common injuries seen and their treatment implications, and (3) provide appropriate return-to-sport recommendations after injury.

Background

Pickleball was invented by Joel Pritchard in Washington with the help of family and friends in 1965. It began as a badminton-like game, but the name “pickleball” was derived from the term “pickle boat” in rowing. These boats consist of nonstarters who are thrown together in a race, just as various equipment is thrown together to create pickleball. The original game used ping-pong paddles and a perforated plastic ball. Formal rules have been established and expanded over time, and the sport grew past the local area, culminating with the first National Pickleball Tournament in Buckeye, Arizona, in 2009.¹

Overview of Rules and Equipment

Pickleball is played on a 20-foot × 44-foot court, compared with 36-foot × 78-foot in tennis (Figure 1). The net height is 34 inches, two inches shorter than a standard tennis net. At the net on both sides of the court, there is a seven-foot “no-volley” zone known as the “kitchen,” where players cannot stand unless returning a volley landing within the “kitchen.” Pickleball can be played as singles or doubles; however, the size of the court does not change between the two. All serves are underhand, and only the serving team can score. Games are usually played to 11 or 21 points. The game must be won by at least two points, otherwise the game continues until a winner by two is determined.

A lightweight plastic ball that contains between 26 and 40 perforations is used (Figure 2). Sizes and the number of holes vary, but typically, larger holes are used for indoor play and smaller holes for outdoor play. Paddles may include multiple materials without limitations on thickness or weight (Figure 3). Official rules dictate that the length of the entire paddle cannot exceed 17 inches, and the combined length and width cannot exceed 24 inches.²

Epidemiology

Pickleball participation continues to increase. According to the Sports and Fitness Industry Association¹ 2022 report, the number of pickleball players rose to 4.8 million, a 14.8% increase from 2020 to 2021. This follows a membership increase of 650% from 2013 to 2019.³ The fastest growing group of participants from 2020 to 2021 was younger than 24 years. Still, most players are considered “masters athletes” (older than 35 years) with 30% of players older than 55 years.¹ The gender composition of players is 60% male and 40% female; however, there is faster growth among female participants. Pickleball is played in all 50 states with an average of 130 new locations available every month.

Benefits of Play

While the benefits of physical fitness in all age groups are well known, pickleball-specific benefits of play have been reported.⁴ Fitness, socialization, and mastery of difficult techniques were found to be key motivators in older pickleball players, with competition being the top perceived benefit of pickleball play.⁵ In addition, some data suggest that older adults who commit to playing pickleball may experience lower levels of depression.⁶

Injury Profiles

Acute Injuries

Adult athletes are more likely to sustain acute pickleball injuries. The annual incidence of such injuries rose over 800% between 2013 and 2017, with most injuries occurring in the age group of 60 to 69 years.³ Nearly 90% of emergency department (ED) pickleball-related injuries were in players older than 50 years.³ Emergency medicine surveillance data report that most pickleball-related injuries seen were caused by sprains or strains (33.2%), followed by fractures (28.1%), with the most common mechanism being a slip, trip, fall, or dive (63.3%).⁷ Sprains and strains were 3.5 times more common in men than in women versus fractures which were 3.5 times more common in women than in men.⁷

The most common body part injured is the wrist (13.2%), followed by the lower leg (12.9%). Surveillance of ED visits after pickleball found that 86.7% of patients with pickleball-related injuries were discharged from the ED versus 96% to 98% of patients with injuries from other racket sports such as tennis, badminton, squash, and racquetball.³ These data likely illuminate the demographic differences and effect of these injuries on pickleball player populations compared with other racket sports.³ The lower leg is the second most common location of injury; however, specific anatomic locations have not been studied.⁷ Within racket sport literature, common acute lower extremity injuries include ankle sprains, Achilles tendon injuries, and hip and groin injuries.^8–10

Wrist Injuries

Acute wrist injuries include a large spectrum of injuries ranging from contusions to ligament or tendon injuries to distal forearm and carpal bone fractures. Although the wrist was the most common body part injured in epidemiologic studies of pickleball, the exact area of the wrist is never specified nor is the nature of the injury (ie, sprain/strain versus fracture).^3,7 Distal radius and ulna fractures account for 18% of all fractures in people older than 65 years and typically occur from a fall on an outstretched hand.¹¹ Patients complain of acute onset of pain after a fall with swelling and tenderness to the distal radius. There may also be a deformity of the distal radius, typically apex volar angulation of the distal radius or a bayonet deformity. A full neurovascular examination should be conducted to ensure that there is no acute vascular injury or nerve injury such as an acute carpal tunnel syndrome. Initial treatment consists of closed reduction and splinting.¹¹ Definitive management depends on the initial displacement of the fracture, as well as radiographic appearance after reduction.¹¹ Extra-articular fractures or minimally displaced fractures with an adequate reduction can be treated with closed reduction and splinting in a sugar-tong splint, followed by short arm casting once swelling has subsided.¹¹ Close follow-up is needed, especially in the early stages of treatment to ensure that the splint or cast is holding an adequate reduction.¹¹ The total immobilization time is typically 6 to 8 weeks.¹¹ For patients with displaced intra-articular fractures with loss of radial height and inclination and loss of volar tilt, surgical management may be beneficial.¹¹ In patients older than 65 years, there is evidence showing minimal long-term benefit to surgical management over nonsurgical management of distal radius fracture even when they have less-than-ideal reductions.¹¹ Of note, distal radius fractures can be the first presenting sign of osteoporosis.¹¹ One study in women between the ages of 60 and 79 years who sustained a distal radius or proximal humerus fracture demonstrated that there was a relative risk of 1.9 of sustaining a hip fracture with the highest being in the first year after their initial injury.¹¹ Patients who present with these fragility fractures should be evaluated and treated for potential osteoporosis.¹¹ This is discussed later in this article.

Ankle Sprains

Ankle injuries are considered one of the most common racket sport injuries⁹ and account for up to 76% of all these injuries.⁹ Lateral ankle sprains of the anterior talofibular ligament (ATFL) are the most common.^9,12 Typically, these occur from an inversion injury from cutting motions or stepping on uneven surfaces. Chronic ankle instability persists in up to 40% of people who sustain an acute injury; thus, prompt treatment and preventive strategies are useful to prevent recurrent ankle sprains.¹² Conservative management with rest, ice, compression, elevation, anti-inflammatories, and functional rehabilitation should be initiated acutely. Early mobilization, nonrigid bracing treatment and taping, and proprioceptive training have all been effective tools for treating and preventing recurrent ankle sprains.¹² Surgical intervention is usually considered only after a rigorous course of nonsurgical treatment has been unsuccessful. Ligament healing time typically requires between 6 and 12 weeks.¹² After return to sport, bracing treatment and taping can be used to help with stability during practice and play.

Achilles Tendon Ruptures

Achilles tendon injuries are common in both tennis and other racket sports. In addition, the prevalence of Achilles tendon ruptures is increasing in the older population.¹³ Increased participation in sports and activities at older age is likely contributing to this.¹³ A review of other racket sport injuries has shown that Achilles tendon injuries make up 6.9% to 9% of acute tennis injuries and 3% to 8.7% of acute badminton injuries.¹⁰ Pickleball play likely places participants at similar risks. The mechanism of injury is classically eccentric loading of the Achilles tendon. Plantaris ruptures and gastrocnemius and soleus strains (also known as “tennis leg”) may present as acute injuries and can mimic Achilles tendon rupture, but these can essentially always be treated conservatively. Historically, nonsurgically treated Achilles tendon injuries resulted in greater re-rupture rates while lessening the risk of wound complications.^14,15 However, more recent data suggest that functional rehabilitation may bring the re-rupture rate closer to the rate after surgical management while minimizing the risks of wound complications.^14,15 Although there are no data to suggest that nonsurgical or surgical management is better in the elderly population, nonsurgical treatment remains more prevalent in patients older than 65 years.¹³ Ultimately, the optimal treatment is likely dependent on both patient and surgeon factors.

Hip and Groin Injuries

Groin and hip injuries occur in sports where quick changes in direction are required. These movements result in eccentric contraction of the adductor muscles, causing high amounts of tension. There is a case report detailing a full-thickness and full-width adductor magnus and common hamstring tendon tear from the ischial tuberosity insertion during pickleball.¹⁶ Athletic hip injuries account for 6% of all sports injuries and are increasing.¹⁷ A meta-analysis examining groin injuries in sports found high levels of evidence suggesting that risk factors for groin injuries included reduced hip adductor strength and reduced sports-specific training. Data also suggest groin injuries were not associated with older age, higher body mass index, or reduced hip range of motion.¹⁸ Management for most acute sport-related hip and groin injuries consists of a period of rest, nonsteroidal anti-inflammatory drugs (NSIADS), and physical therapy. For adductor tendon strains, local steroid injections to the adductor longus enthesis with either dexamethasone or triamcinolone mixed with local anesthetic have been shown to provide reasonable relief, especially in early stages of inflammation.¹⁷ Surgical treatments exist for recalcitrant tendinitis or enthesopathy. In the setting of complete ruptures of adductor tendons, studies have supported both surgical and nonsurgical management; however, most of the studies describing surgical management are in amateur and professional athlete populations.¹⁷ Gradual sport-specific training may help prevent groin injuries.¹⁸

Low Back Injuries

The 12-month prevalence of low back pain within racket sport athletes ranges from 31% to 80%.¹⁹ The most common low back injury in tennis is lumbar strain with the serve being the most likely time to sustain a back injury.⁸ Patients typically present with activity-related insidious onset of back pain. In cases of radiculopathy, patients may present with shooting pain down a dermatomal distribution. Neurogenic claudication presents similarly but varies with position, namely improvement with lumbar flexion and worsening with extension. Patients with prolonged symptoms lasting over 6 weeks or symptoms concerning for more serious pathologies such as malignancy, infection, or cauda equina should be evaluated with lumbar radiographs and possibly MRI.²⁰ Most low back pain is benign and can be treated with education about the natural course of low back pain and a home exercise program.²⁰ Patients should be encouraged to continue activity with modifications as needed and discouraged from bed rest. Pharmacologic intervention with NSAIDs is considered second line after exercise or a course of physical therapy has been attempted.²⁰ Treatment with routine use of muscle relaxants or opioids is not recommended.²⁰ Competitive play should cease until pain improves. Cases that fail 6 to 12 weeks of conservative management may require evaluation and treatment.²⁰

Chronic Injuries

Extensor Carpi Ulnaris Tendinopathy

Data on tennis injuries suggest that several upper extremity injuries are chronic in nature, with extensor carpi ulnaris (ECU) tendinitis being one of the most prevalent.²¹ ECU tendinitis can present insidiously in racket sport athletes, including pickleball players, and can be attributed to ulnar deviation of the wrist during forehand and backhand strokes.^8,21 Physical examination may reveal tenderness along the ECU tendon sheath, a positive ECU synergy test, and instability of the ECU tendon.²¹ Proposed stroke modifications to prevent recurrence and limit pain of ECU tendinitis include reducing aggressive ulnar deviation, lowering the body to the level of the ball, and delaying wrist flexion until the end of the stroke.²² Treatment of ECU tendinitis may include rest, NSAIDs, and splinting.²¹ Corticosteroid injections may be considered in the ECU tendon sheath for refractory cases.²¹ Acute ECU tendon subluxation can be treated with immobilization in pronation and dorsiflexion. If symptomatic subluxation continues despite immobilization for up to 6 weeks, reconstruction of the ECU subsheath may be indicated.²¹ In a small study of professional tennis players treated with ECU subsheath reconstruction, return to preinjury level of play occurred at an average of 8 months after surgery.²¹

Lateral Epicondylitis

When considering racket sport athletes, about half of all tennis players develop pain around the elbow, most of which is lateral epicondylitis.²¹ Patients may complain of lateral elbow pain at the common extensor origin and demonstrate weakness in grip and wrist extension on examination. Diagnosis is clinical and rarely is imaging indicated, except in chronic or refractory cases for which MRI may be performed.²³ Conservative treatment is successful in most cases.²¹ NSAIDs, icing, stretching, physical therapy, and bracing treatment have all been recommended, but 80% to 90% of cases resolve spontaneously with removal of the offending activity. Racket sport-specific changes to treat lateral epicondylitis include adjusting the racket to decrease vibrations, decreasing grip size, relaxing the grip after ball impact, and changing the stroke technique from one-handed to two-handed strokes to aid in shock absorption.²¹ Surgery is rarely indicated for cases of lateral epicondylitis refractory to conservative measures, with one study reporting only 8% of patients requiring surgical intervention.²³

Rotator Cuff Tendinopathy

Rotator cuff tendinopathy is common in racket sports, although it is suggested that there may be a relatively lower risk of shoulder injury with pickleball due to less overhead motion.^16,24 Pain is usually described as a dull ache over the lateral deltoid region with aggravation during overhead movements. Nighttime pain may often be associated with rotator cuff pathology. Patients may also have decreased active range of motion of the shoulder. Treatment for rotator cuff tendinopathy may include conservative measures including physical therapy focusing on core and scapular strengthening. Data suggest that focused physiotherapy had similar clinical outcomes compared with surgical management for small and medium-sized tears in patients with an average age of approximately 60 years.²⁵ Another study of patients in this same age group found that physical therapy alone was effective for atraumatic full-thickness tears in 75% of cases at 2 years.²⁵ There may be a short-term benefit to subacromial corticosteroid injections in terms of pain management; however, there is no long-term benefit shown in the treatment of rotator cuff disease.²⁵ Surgical management in the form of arthroscopic or open repair or reconstruction of the rotator cuff tear may be indicated when debilitating pain continues despite nonsurgical measures for at least 3 to 6 months.²⁵ There are currently no studies specifically looking at return to pickleball play after rotator cuff repair. According to a recent meta-analysis, the rate of return to sport at preinjury level or higher in the recreational athlete after a rotator cuff repair is 73.3%.²⁶ Although this study did not conduct subanalysis of the recreational athletes by age, the authors did report that age did not affect return to sport or return to previous level of play. In addition, a singular study included in the meta-analysis found a return-to-sport rate of 88.9% in recreational tennis players with an average age of 57 years.²⁷

Other Injuries

Eye Injuries

Owing to the fast-paced nature of the sport, pickleball players are at risk of eye injuries. These injuries are less common compared with tennis, which is thought to be due to the slower ball speed and weight in pickleball. Among players older than 60 years specifically, emergency medicine data report 1.4% of tennis-related injuries in the ED to be eye injuries versus 0.5% of pickleball-related injuries.⁷ There are notable case reports of significant eye injuries seen from pickleball including retinal tears, corneal abrasions, iritis, and traumatic lens subluxations, which required ophthalmologic intervention.^28,29 In general, suspected eye injuries with vision changes should be assessed by an ophthalmologic provider emergently or urgently. Eye protection is recommended for racket sports, specifically as outlined by the American Society of Testing and Materials Article F3164-19 that describes the international standards for eye protectors for racket sports. Essentially, the eye protector should consist of a lens made of durable plastic (usually polycarbonate) material that protects the wearer’s eyes from the high impact of a ball and is shatter-resistant.²⁸

Heat Injuries

Masters athletes are at higher risk of heat-related injury because of a decreased ability to thermoregulate than younger players.³⁰ Emergency department data report that 2.2% of all pickleball-related injuries in the ED are due to heat-related illness.⁷ Heat injuries present on a spectrum from muscle cramps and heat exhaustion to heatstroke. Risk factors for heatstroke include low fitness level, obesity, poor hydration status, medical comorbidities such as cardiovascular disease or sweat gland dysfunction, and a history of heatstroke³⁰ Downstream effects of heatstroke include rhabdomyolysis, acute kidney injury, hypoglycemia, and hyponatremia.³⁰ Heatstroke involves central nervous system (CNS) dysfunction and may be fatal.³⁰ Initial findings may include lethargy, decreased or absent perspiration, or altered mental status.³⁰ Prevention of heat injury includes physical fitness, appropriate hydration, taking breaks, and recognizing the signs of heat injury.³⁰ Treatment for acute heat injury includes moving the patient to a shaded area for cooling him or her.³⁰ Appropriate fluid, electrolyte, and glucose management is critical.³⁰ If additional serious medical issues are suspected, the patient should be taken to a nearby medical tent with intravenous fluid and point-of-care laboratory testing capabilities or the nearest ED.³⁰

Injury Prevention

The 2018 US Physical Activity Guidelines report strong evidence that regular moderate-to-vigorous physical activity in older adults promotes improved physical function reducing the risk of falls and fall-related injuries.⁴ This exercise also helps older adults maintain independence. Federal guidelines define regular exercise as 150 to 300 minutes per week of moderate-intensity aerobic physical activity.⁴ Even for those who perform little to no activity at baseline, replacement of sedentary behavior with light activity reduces all-cause mortality, incidence of cardiovascular disease, and incidence of type 2 diabetes.⁴ Generalized physical fitness is also suggested to help relieve fatigue associated with extended pickleball play.²⁴

To prevent acute injury, authors with pickleball experience have suggested that players be accustomed to the “ready position,” avoid backpedaling, and limit the duration of play to avoid injury.¹⁶ The “ready position” is a wide-based, bent-knee, split stance that provides a stable base and may prevent tripping and falling while making quick movements (Figure 4). The addition of resistance training may help prevent injury by counteracting sarcopenia, or decreased muscle mass and strength, and osteopenia.³¹ Resistance training programs for older adults should focus on including appropriate resistance training program variables to create physiologic adaptations to prepare them for play and provide functional benefits such as fall prevention and preserving independence. The National Strength and Conditioning Association recommends resistance training sessions 2 to 3 times per week per major muscle group (ie, chest, shoulders, arms, and legs) They also specify that training sessions should consist of 8 to 10 different exercises with 1 to 3 sets of 8 to 15 repetitions per exercise.³¹

Bone health may certainly contribute to acute injury prevention in pickleball players because of the advanced age of the average participant. Older women are at particular risk because of age-dependent decrease in bone mineral density.³² These sex differences may account for the markedly higher wrist fracture risk as documented in female pickleball players. Prevention and treatment of osteoporosis and osteopenia is key to maintaining bone health. Prevention strategies include regular physical activity and age and sex-specific vitamin D and calcium supplementation.³² For those with dual x-ray absorptiometry (DEXA) scan-confirmed osteoporosis, treatment strategies include treatment doses of vitamin D and calcium and antiresorptive pharmacotherapy such as bisphosphonates and denosumab or anabolic agents such as teriparatide.³² Referral to a comprehensive osteoporosis clinic after initial evaluation and treatment may also be beneficial.³²

Pickleball After Total Joint Arthroplasty

Return to activity is a common goal for both patients and arthroplasty surgeons. Unfortunately, even for active patients, surgeon recommendations vary widely.³³ A survey of runners undergoing total joint arthroplasty demonstrated that 28% of surgeons recommended that the patient avoid running postoperatively while 30% offered no recommendation at all.³³ Similarly, multiple studies have demonstrated that the most common reason for patients not to return to sport was surgeon recommendation.^34–36

Recent meta-analyses have attempted to offer guidelines to aid both surgeons and patients seeking to remain active after joint arthroplasty.^34,35 After total knee arthroplasty or unicompartmental knee arthroplasty, the data suggest that patients can return to sport around the 12-week mark postoperatively. Experience with a specific sport was a strong predictor of return to sport. The authors recommended that intermediate-impact activities, such as doubles tennis, were allowed with experience. Both singles tennis and racquetball were considered high impact and, therefore, not recommended without a collective decision made between the patient and surgeon.³⁴

After total hip arthroplasty, Sowers et al³⁵ found a similar conclusion, with doubles tennis unanimously allowed or allowed with experience in the available literature, while singles tennis, racquetball, and squash considered not recommended or without consensus. Pickleball, which gained much of its popularity after the subjective impact scores were assigned, is completely absent from these recommendations and subsequent analysis, despite its notable popularity in the patient demographic likely to use joint arthroplasty.^34,35

Pickleball is likely to require lower impact than singles tennis because of smaller court sizes, slower ball speed, and reduced forces in swinging and serving mechanics, and the authors would consider it an intermediate-impact sport, similar to doubles tennis, and, therefore, recommend patients be encouraged to participate with appropriate experience and conditioning. Ultimately, surgeons familiar with the sport and its requirements should strive to make specific recommendations for their patients on a case-by-case basis after hip or knee arthroplasty.

Despite lagging both total hip arthroplasty and total knee arthroplasty in procedures performed annually, the prevalence of shoulder arthroplasty including anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty (rTSA) is growing at a more rapid rate in the United States.³⁷ Consequently, the data on return to sport after TSA have also increased.^38–40 A recent meta-analysis demonstrated that 80.7% of patients were able to return to sport after TSA if they were practicing the sport 3 months before surgery.³⁸ However, surgeons should be cautious in extrapolating these data when considering overhead activities, such as tennis, which may be associated with lower return-to-sport rates.⁴⁰ In addition, multiple studies have found rTSA to be associated with lower return-to-sport rates than anatomic total shoulder arthroplasty, which is likely multifactorial in nature.^39,40 Specifically, Davey found a return-to-tennis rate of only 50% in patients undergoing rTSA.³⁹ While play may not be excluded after TSA, attributes of both the surgery and the specific racquet nature of pickleball may yield lower return-to-play rates in these patients.

Conclusion

Pickleball is growing rapidly among all age groups, but still predominantly among older adults. As participation continues to rise, familiarity with both the game of pickleball and the possible injuries sustained by its players will help orthopaedic surgeons mitigate, treat, and recommend return to play for those patients they encounter in practice.