Expert Insights in Preventing Pickleball Injuries

I started playing pickleball in 2017, well before the pandemic. My background was hockey and racquetball, so I found a natural fit playing pickleball because I’d always enjoyed playing ping pong. I had my hand-eye coordination from playing hockey and ping pong and playing racquetball. So, this this sport kind of fell into my lap, and was something I really enjoyed.

I have a very high skill rating. I do play national level tournaments and have a few medals, but for the most part I take care of a majority of the local professional athletes that play in the United Pickleball Association (UPA) Tour here in South Florida, and then I take care of both the regular touring pros and the senior professionals who live in the area.

While there’s a lot of stuff out there on the Internet and from various organizations, I wanted you to hear it from the guy who’s on the court in between the lines treating these active professional athletes.

Where is pickleball today compared to years ago? Right now, 36.5 million people are playing the sport, compared to about 2 million who were playing when I started.¹ So the sport has just exploded in the last 8 years and especially since COVID-19.

We think pickleball players are really this older, 50-plus population. The largest number of pickleball players, age- and demographic-wise in the United States, representing about 28% of all players, is ages 18 to 34.² There are tens of thousands of places to play pickleball in the US—we’re literally converting tennis courts into pickleball facilities.

A Closer Look at Injury Prevention and Exercises

There are 3 major injuries that I see in the lower extremity in pickleball players: Achilles tendonitis, ankle sprains, and plantar fasciitis.

How can we prevent injury? The biggest harbinger to injury that I find is a lack of warm-up. If you were to ask any of these patients when they come in with your injury, “Did you warm up before you played?” the answer is going to be no. Almost 80% of the time patients will say they hit the ball a little before playing but they didn’t actually warm up the body physically.

I then talk with patients about dynamic stretching and dynamic foot movement. You can also talk about how to do 3-dimensional stretching and opening up the hips and warming up.

There are certain tools here that that we need to talk about as far as training, such as massage pistols. They help to heat the muscles up before you even start doing anything. The whole idea is to use high-frequency massage therapy to increase blood flow to the muscles to start loosening them up, so that when you go to start playing, you’re already warmed up. You’re not starting static or cold. Patients can also warm up the quadricep, calf, hamstring, peroneal, hip, and gluteal muscles.

With a massage pistol, I advise spending about 45 seconds per muscle group at high frequency. Not every patient can tolerate the high frequency, but your patients who have larger skeletal muscle mass are going to need to use more power to get into the muscle. Women may not  go to full power with the massage pistol. Patients should use the massage pistol about 30–45 seconds per muscle group per extremity.

Patients should also do basic static stretching like runner stretches to loosen up the calf muscle. They would do inverted pigeon-toe stretching to loosen up the lower back and soleus almost like doing a Pilates plank. They would do this up against the wall, pigeoning the legs to do a figure 4, leaning forward and stretching the gluteus medius, for about 6 to 7 seconds. That’s all that I advise my patients to stretch—a 6-second stretch, then come back up and reset the stretch again.

The whole idea is to do active, dynamic stretching, not static stretching. You want to get that muscle pulling, contracting, pulling, and contracting, pulling and contracting with the hip. It’s really important because the hip is where I find most of the misfires occur in patients with pickleball injuries. It doesn’t start from the Achilles tendon in the cases that I see; that’s not the pathology. The pathology is much more proximal.

When the iliopsoas muscle doesn’t fire it causes this down chain reaction of overuse injury through the hip through the quadriceps into the calf. The majority of plantar fasciitis and Achilles tendonitis that I see is actually from calf misfiring or overfiring.

One of the other warmup things that we can do is make sure that patients have a trigger point ball, which is a 5-inch ball available online. Patients would roll this into the muscle to try to loosen it up.

All of this is designed to really just accelerate the patient’s ability to be more functionally active on the court. When that happens I find they get better outcomes, they have less pain afterward, and they have a quicker recovery. They also don’t injure as easily, in my experience.

Injuries can still happen but by at least by incorporating some really good education on stretching and dynamic therapy with functional medicine, you can actually really make a difference in your patient’s functional ability on the court.

Strengthening exercises are not as much cardio, but doing more weight-resisted work, working your core, working your quads, building your hamstrings, and building skeletal muscle mass. That’s what helps everything. When you strengthen around a joint, the joint is not so susceptible to injury. Patients who have stronger quadriceps and hamstring muscle groups don’t have as many knee replacements. When the knee joint is taking on too much stress, then you start breaking down cartilage which can lead to chondromalacia, and then eventually meniscus tears, which can eventually contribute to a total knee replacement when patients are in their 50s and 60s.

Patients can do core strengthening and isolated leg exercises with leg strengthening, calf strengthening with resisted calf exercises with using the body weight with the counter, pushing up on their toes and lifting their body weight on one leg at a time. That’s the resisted training I feel they need.

The other thing is to talk to your patients about agility drills and about what type of training are they doing to increase their footwork, because better footwork may help to minimize ankle injuries.

Final Thoughts

The whole idea of this is to learn how to build a niche business out of pickleball, even if you don’t play. We are the preeminent foot and ankle medical and surgical experts of the lower leg. We need to make sure that we are the experts when it comes to pickleball injuries.

Dr. Lullove is in practice in Coconut Creek, Fla. He is the Chief Medical Officer of the West Boca Center for Wound Healing. Dr. Lullove discloses he is a shareholder of Winners Edge Pickleball Shoes.

References
1.    APP Pickleball. APP reveals 36.5 million adult Americans played pickleball in 2022. Published Jan. 4, 2023. Accessed Nov. 13, 2024.
2.     APP Pickleball. New APP research reveals nearly 50 million adult Americans have played pickleball in the last 12 months; average age drops to 35. Published March 29, 2023. Accessed Nov. 13, 2024.