Although pickleball has been around for over 50 years, there has been nothing less than a meteoric rise in its popularity over the past few years.
A sport that was once relegated to “retirees” has caught the attention of enthusiasts of all ages. With this broad-ranging attraction, pickleball is now the fastest growing sport in the United States.1
The fast-paced racquet sport’s popularity has soared over the past few years to the point that a professional pickleball league debuted this past year, with investors including Lebron James throwing their personal and financial support behind it.2 Pickleball has even stirred controversy across the country as municipalities bicker over the replacement of old tennis courts and skateparks with new pickleball courts and “the cacophony of pings that accompany them.”3
The rise of pickleball rise from an obscure hobby to an all-American pastime warrants some attention, including that of the sports medicine provider. This article will give the reader a brief overview of the sport, the most common injuries seen in the community and ways to prevent them.
The Origin of Pickleball
Pickleball was invented in 1965 by former Washington state congressman Joel Pritchard with friends Bill Bell and Barney McCallum while on summer vacation with their families on Bainbridge Island, Wash.4 The men were looking for a way to keep their children occupied with an incomplete assortment of various athletic equipment—the first game being played with ping pong paddles, a whiffle ball and a badminton net. With the rules being made up ad hoc, the game soon came to resemble that which is played today.
The name of the sport itself is shrouded in mystery; at least three different origin stories claim to be the truth. The first and most well-known version is that the game was named after the Pritchard family dog, “Pickles,” known to be a frequent fixture around the early games,5 Another version from Joel Pritchard’s wife, Joan, was that she came up with the name after the odd collection of equipment reminded her of the “pickle boat crew” where oarsmen are chosen from the leftovers of other boats.6 And in yet a third version, Bill Bell would tell friends he came up with the name because he enjoyed putting his opponents “in a pickle.”7
Pickleball Rules
A pickleball court is similar in design to that of a tennis court, but roughly half the size at 20’ wide and 44’ long. The court is divided into halves by a net that is 36 inches tall, again shorter than its tennis counterpart. Serving must be made diagonally from behind the baseline and the server must keep one foot behind the baseline until the serve is made. The serve must clear “the kitchen,” a no-volley zone in the middle of the court. If the serve is good, the receiving team can return the ball. Games are played to 11 points and a team must win by two points.8
Pickleball Injuries
Although pickleball is marketed as a low impact sport that is joint friendly, the fast pace of play still places athletes of all ages at risk for injury. Pickleball injuries alone could cost Americans nearly $500 million in medical costs this year according to one recent analysis.9 Although the data regarding pickleball injuries is nascent, it is sure to provide helpful information regarding a rapidly growing patient population. Reviewing the epidemiology and injury mechanisms of the sport will help with patient education as well as managing patient expectations.
Incidence and Injury Patterns
Pickleball is generally thought of as a safer alternative to other racquet sports due to its small court size and relatively small area of ground required to cover. However, injury rates in similar sports like tennis, racquetball and squash have decreased over the past few years, while pickleball injury numbers have increased nearly ninefold in the past decade alone.10 Using data collected from NEISS, the most recent annual estimated number of pickleball related injuries was approximately 19,000. The age distribution of these injuries was skewed heavily towards the geriatric population as 91% of injuries occurred in patients 50 years of age or older. Overall, the most frequent injuries were sprains/strains (33%), fractures (28%), and contusions/abrasions (11%).
Lower Extremity
Injuries to the lower extremity accounted for 29% of all injuries. This statistic represents injuries from the hip proximally to the foot and ankle distally. The most common injuries noted were lower leg (12.9%), ankle (6.1%), knee (5.9%), and foot (2.1%). Case reports describing a proximal hamstring avulsion as well as an adductor magnus tear have also been reported.11
Although not recorded in the literature, lower extremity soft tissue structures are certainly at risk during competition. The constant eccentric contracture caused by the frequent acceleration/deceleration and sudden movements required by the sport in athletes of varying levels of fitness leave the possibility of Achilles tendon and ACL ruptures, to name a couple, in high concern.
Upper Extremity
Injuries to the upper extremity are more common than lower extremity injuries, accounting for 33% of all injuries. The most common of these injuries were to the wrist (13.2%), shoulder (5.4%), finger (4.1%), and elbow (2.9%).
Notably, female athletes were more than nine times more likely to suffer a wrist fracture than male athletes. The popularity of the sport amongst geriatric patients would theoretically place older female athletes with lower bone density at risk of fracture. However, the risk of wrist fracture was less severe amongst senior female athletes compared to senior male athletes.
Other Injuries
Injuries to the head (12%), abdomen (11%), and face (3.5%) were also reported as common injuries. These include concussions, internal injuries and lacerations. Although not as common, injuries to the eye accounted for 0.7% of injuries. The most common cause of this injury was being hit by a ball. The rate of eyeball injuries is notably lower in pickleball compared to tennis (1.5%).
Treatment
Although notably sparse in reviewing the literature, one study looking at treatment of upper extremity injuries of pickleball and paddleball players found that 80% of injuries were treated non-operatively with conservative management consisting of steroid injections, splinting, or physical therapy.12 Of the injuries treated surgically, ORIF of distal radius fractures was the most common procedure performed (72%). The rate of surgical fixation is higher than the general population. This may be due to the mechanism of injury as falls during competition would generate higher energy leading to greater fracture displacement. It may also be explained by the patient population. These patients, whether young or old, are athletes interested in returning to competition and as such may be more interested in surgical fixation.
Injury Prevention
Players can reduce their risk of injury by taking several preventive measures. These measures include using proper technique when hitting shots, gradually increasing the intensity and duration of play by taking a “warm-up” session, and taking adequate rest periods to allow for recovery.13-14
Stretching prior to, throughout, and after competition can help prevent joint tightness and avoid both chronic and acute injuries. Players should also wear proper protective gear, such as wrist guards, ankle braces, and eyewear, and ensure that the court surface is free of hazards. Keeping the court in good playing condition and avoiding playing on wet surfaces can also decrease the potential for injury.
Finally, general fitness remains highly important. Engaging in a daily routine that includes stretching, gentle strength training, and aerobic activity will help minimize the risk of injury for all pickleball players. Staying hydrated and maintaining a healthy diet can also help prevent injuries by promoting proper muscle and joint function. Players should be aware of their limitations and listen to their bodies. If pain or discomfort is experienced, it is important to take a break and seek medical attention if necessary to prevent further injury.
Conclusion
As pickleball continues to gain popularity, it is important for the sports medicine provider to understand the basics of the game itself, the physical demands placed on participants, and the common injuries. With this knowledge, the care team can not only better treat the patient, but also implement the most appropriate return-to-play plan.
Although the majority of pickleball injuries are common overuse injuries, providers should be prepared to see and identify these and more serious injuries in their clinics – because they do happen. Awareness of these injuries allows the physician to most effectively treat their patients, as well as answer their questions about the potential risks involved in playing the sport. Preventive measures can ensure that participants of all ages can continue to enjoy the immensely popular game of pickleball while minimizing the risk of injury.
References
- USA Pickleball Association | Become a Member Today. Published 2020. Accessed August 25, 2023.
- Mather V. Move Over … Everything? Here Comes Major League Pickleball. The New York Times. Published October 3, 2022. Accessed August 25, 2023.
- Sheets C. Pickleball noise is fueling neighborhood drama from coast to coast. Los Angeles Times. Published March 3, 2022. Accessed August 25, 2023.
- USA Pickleball. History of the Game. USA Pickleball. Published June 27, 2013. Accessed August 25, 2023.
- Dollard W. 404. Pickleball Magazine. Accessed August 25, 2023.
- History of Pickleball | How did pickleball get its name? Pickleball Land. Published January 13, 2019. Accessed August 25, 2023.
- Lucore J, Youngren B. History of Pickleball : More than 50 Years of Fun! Two Picklers Press; 2018.
- Rules Summary - USA Pickleball. USA Pickleball. Published December 23, 2013. Accessed August 25, 2023.
- Cerullo M. Pickleball injuries could cost Americans up to $500 million this year, analysis finds - CBS News. www.cbsnews.com. Published June 27, 2023. Accessed August 25, 2023.
- Forrester MB. Pickleball-Related Injuries Treated in Emergency Departments. The Journal of Emergency Medicine. 2019;58(2). doi:https://doi.org/10.1016/j.jeme...
- Vitale K, Liu S. Pickleball: Review and Clinical Recommendations for this Fast-growing Sport. Current Sports Medicine Reports. 2020;19(10):406-413. doi:https://doi.org/10.1249/jsr.00...
- Kasper A, Gibbons J, Abboudi J, et al. Pickleball- and Paddleball-Related Injuries to the Upper Extremity. Cureus. Published online June 1, 2023. doi:https://doi.org/10.7759/cureus...
- Quail MT. Caring for patients with pickleball injuries. Nursing. 2019;49(4):16-17. doi:https://doi.org/10.1097/01.nur...
- McCallum K. Playing Pickleball? Here Are 5 Tips for Avoiding Injuries. www.houstonmethodist.org. Published November 16, 2022. Accessed August 25, 2023.