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Dinking, Chopping, and Lobbing: Considerations for Preventing and Managing Pickleball Injuries
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Podiatry Today or HMP Global, their employees, and affiliates.
As America’s fastest growing sport, with over 19% of adults taking up the paddle within the past year, the pickleball community continues to grow.1 For the reader unaware of this popular game that dates back to 1965, pickleball is a racquet sport, played both indoors and outdoors. Regulated by its own unique set rules similar to tennis, a match consists of 2 or 4 players hitting a hollow plastic ball over a net. As the court remains relatively small, measuring 44 feet long by 20 wide, agility and balance are key. Given the simplicity of its rules and low-impact nature along with the opportunity for a social outing, this sport provides an enjoyable challenge for every level of athlete.
From novice to expert, whether young or seasoned, pickleball injuries remain a constant threat. Previous research has shown that patients with strains and sprains followed by fractures present most commonly to the emergency room.2 Furthermore, the majority of such injuries affected the lower extremity. It is estimated that such injuries cost Americans between $250 and $500 million in medical costs this year alone.3 Though up to 88% of patients are released from the emergency department, prevention, management, and rehabilitation following these injuries proves paramount.2
A study performed by Weiss and colleagues evaluated senior pickleball players and common injuries associated with the sport.4 The most common mechanism of injury was “slip/trip/fall/dive” with strains/sprains (33.2%) being the most common injury followed by fractures (28.1%).4 The wrist is the most commonly injured body part (13.2%) in females as compared to males, in whom the lower extremity is the most commonly injured area (39.8%). When comparing gender-related injuries, women are three times more likely to suffer a fracture as compared to men who are more likely to have a sprain or strain.5 Patients greater than 60 years of age should be carefully evaluated in the emergency room or clinic to ensure proper diagnosis of injuries after sport. It is important to educate your patients of risks associated with participating in this activity, especially those with advanced age, given that lower bone density and less general conditioning can increase the risk of injury.
Whether playing pickleball indoors or outdoors, players should consider the types of shoes being worn. As this sport relies on quick and agile moves to return serves or volleys, players will want shoes that prevent or limit strains or sprains of the foot and ankle. Pickleball shoes possess a rubber sole designed to increase traction in both front-to-back as well as lateral movements. Moreover, the soles flare outwards to provide greater stability.
Aside from shoe gear, a proper warmup and cool down from the match can be useful for players to prevent issues after play. Just like other physical activities, it is important to warm up the body prior to playing with a cool down and stretch to avoid long-lasting soreness and injuries. Providers can also educate their patients that are interested in increasing their daily activity by explaining the risks of sporting injuries if too much movement is performed in a short period of time. One example is the dreaded “weekend warrior” sustaining Achilles tendon ruptures. While publications did not explicitly discuss an increase in Achilles tendon ruptures due to this activity, it would be wise to consider this as a differential diagnosis, especially in the middle-aged to late-aged patient population.
Just like with any other sporting injury affecting the lower extremity, pickleball players can expect similar nonoperative treatment regimens depending on the severity of their symptoms.5 Patients with mild to moderate ankle sprains will likely use an ankle lace-up brace with physical therapy compared to those with a more severe injury who require immobilization in a controlled ankle motion (CAM) boot before ankle rehabilitation is initiated.5 Achilles tendinitis, posterior tibial tendonitis, or peroneal tendonitis may occur as well. Depending on the severity of such injury, patients can expect to be placed in a CAM boot prior to physical therapy and then transitioned to a lace-up ankle brace if further support is needed during sport. Patients may also develop plantar fasciitis, which, again, can be treated with a wide range of nonoperative modalities such as accommodative shoe gear or orthotics, steroid injections, topical analgesics, physical therapy/stretching, or in more severe cases, CAM boot immobilization prior to returning to sport.
Although less common, fractures have been reported as lower extremity pickleball injuries. While not explicitly noted, consideration for stress fractures should be made if presented with an insidious onset after beginning the sport. Depending on the severity, some patients may only require nonoperative management which will be non-weight-bearing in a CAM boot or splint for 4–6 weeks or until fracture consolidation is noted. Following this, patients will transition into regular shoe gear with physical therapy.6 Those needing surgery will undergo open reduction internal fixation with similar postoperative considerations.7 Fragility fractures should also be considered for specific perioperative protocols and considerations such as stronger internal fixation constructs with minimally invasive techniques, increased vitamin D and calcium intake, and prolonged immobilization.8
In closing, as the nation's population ages and the number of those partaking in pickleball continues to grow, sports-related injuries will invariably increase. Specific to the lower extremity, prevention should be focused on proper fitting shoes for indoor versus outdoor courts. Due to the agility needed during gameplay, one should consider programs to strengthen the ankle and ultimately improve balance. Moreover, for those just beginning this exciting sport, you should ease into the activity to prevent any weekend warrior–type injuries. Above all else, have fun and enjoy the game.
Dr. Mateen is a staff physician in the Orthopedic Department at Hackensack University Medical Center New Jersey.
Dr. Casciato is faculty at the Orlando VA Medical Center in Orlando, FL.
References
1. Association of Pickleball Players. New APP research reveals nearly 50 million adult Americans have played in pickleball in the last 12 months; average age drops to 35. Published March 29, 2023.
2. Forrester MB. Pickleball-related injuries treated in emergency departments. J Emerg Med. 2020 Feb;58(2):275-279. doi: 10.1016/j.jemermed.2019.09.016. Epub 2019 Nov 30. PMID: 31796221.
3. Jackson S. Pickleball could be responsible for up to $500 million in medical costs this year, one industry watcher says. Business Insider. Accessed 13 Aug. 2023.
4. Weiss H, Dougherty J, DiMaggio C. Non-fatal senior pickleball and tennis-related injuries treated in United States emergency departments, 2010-2019. Inj Epidemiol. 2021 May 3;8(1):34. doi: 10.1186/s40621-021-00327-9.
5. Michels F, Wastyn H, Pottel H, Stockmans F, Vereecke E, Matricali G. The presence of persistent symptoms 12 months following a first lateral ankle sprain: A systematic review and meta-analysis. Foot Ankle Surg. 2022 Oct;28(7):817-826.
6. Kortekangas T, Lehtola R, Leskelä HV, et al. Surgery versus non-operative treatment for ER-stress unstable Weber-B unimalleolar fractures: a study protocol for a prospective randomized non-inferiority (Super-Fin) trial. BMJ Surg Interv Health Technol. 2021 Dec 7;3(1):e000098. doi: 10.1136/bmjsit-2021-000098.
7. Yip G, Hay D, Stringfellow T, Ahluwalia A, Ahluwalia R. Assessment and management of adult ankle fractures: understanding the evidence. Br J Hosp Med (Lond). 2021 May 2;82(5):1-9.
8. Casciato D, DeGenova DT, Hill Z, et al. Association between pronation external rotation IV fracture pattern and regional bone density. Foot Ankle Spec. 2023 May 17:19386400231173163
Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.
