Evaluation of Pickleball-Related Injuries at a Single Institution From 2017 to 2022

Methods

We conducted a descriptive epidemiologic study of pickleball-related injuries at our institution (Vanderbilt University Medical Center) from January 1, 2017, to December 31, 2022. We used the Vanderbilt Research Derivative to systematically query the electronic health record (EHR) system for any mention of keywords “pickle,”“pickleball,” or “pickle ball.” Patient charts flagged by the search were then manually reviewed by 2 independent reviewers (S.D.H. and K.L.H.) and screened for inclusion. To capture the overall prevalence of orthopaedic injuries in pickleball and to present a full picture of the spectrum of pickleball illnesses, participants were eligible for inclusion if there was any documentation in their chart of evaluation by a medical professional for an injury or ailment identified in relation to a pickleball incident during the collection period. Patients were excluded if they did not have a pickleball-related injury event or if their injury occurred outside of the timeframe of the study. This study was deemed exempt from institutional review board approval.

Data were collected using a structured extraction form developed a priori. We collected information on patient characteristics; injury diagnosis, category, and location; injury evaluation location and timing; diagnostic testing; treatment/interventions; follow-up; and interaction with an orthopaedic specialist. Each chart was manually reviewed to ensure proper classification of injury events—including quantifying the presence of multiple injuries among patients (ie, single evaluation for multiple unique injuries, as well as independent evaluations for subsequent injuries) and to ensure proper classification of injury events (ie, avoid falsely duplicating/elevating injury counts in event of multiple follow-up visits associated with a single injury). If a single patient sustained multiple injuries, the first injury was defined as the injury at their initial evaluation. If a patient had multiple injuries at their initial evaluation, then each of the injuries was counted as a separate “first injury.” All injuries were defined as any unique injury sustained throughout the study period.

Results

Age at Injury

Age at injury ranged from 12 to 82 years, with a median age of injury of 65 years (interquartile range, 57-70 years) and a strongly left-skewed distribution (Figure 1). The mean age at injury (62 ± 13.1 years) was significantly greater than the mean age of pickleball participants nationally (36 years^1,20) (P < .001). The mean age of injury over the study period ranged from 59.9 (in 2022) to 65.1 (in 2019), and although linear regression revealed a statistically significant decrease in the age of injury of 1 year per study year (β = 0.99; P = .003), there was no significant difference in age across the study period (Appendix Table A1).

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Figure 1.

Age of patients with pickleball-related injury diagnosis (N = 618) at Vanderbilt University Medical Center, 2017-2022.

Pickleball Injuries During the Study Period

The number of pickleball injuries increased exponentially from 2017 to 2022 (y = 24.326e^0.3586x; R² = 0.97), with a 6.8-fold increase in injuries in 2022 as compared with 2017 (Figure 2). The rate of increase in injuries across this study was significantly greater than the rate of increase in participation in pickleball nationally from 2017 to 2022 (P = .002).

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Figure 2.

Distribution of pickleball-related injuries from 2017 to 2022. The trend line for all injuries was fit with an exponential model across the study duration (y = 24.326e^0.3586x; R² = 0.97).

Injuries by Category

Injuries were divided into several categories as shown in Appendix Figure A1, with soft tissue strain or rupture (n = 296; 47.9%) being the most prevalent injury category. Overall, the most common diagnoses were injuries to the rotator cuff (n = 67; 10.8%), arthritis-related pain of any joint (n = 62; 10%), back pain/strain (n = 48; 7.8%), and calf strain or tear (n = 35; 5.7%) (Table 1). Among nonorthopaedic injuries, the most common injuries were cardiac-related chest pain/palpitations (n = 24; 3.9%) and facial lacerations (n = 15; 2.4%) (Table 1). There was no observable trend in nonorthopaedic injuries throughout the study period, indicating a relatively proportional increase in both orthopaedic and nonorthopaedic conditions over the study period. When further divided by age group, soft tissue injuries (including strain/tear and inflammation) became less common in patients >60 years, while fractures (most commonly hip or wrist fractures) and arthritis-related pain became more common (Figure 3).

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Table 1

Diagnosis of Pickleball-Related Injuries at Vanderbilt University Medical Center, 2017-2022 ^a

Injury Diagnosis (Orthopaedic)	n (%)	Injury Diagnosis (Nonorthopaedic)	n (%)
Rotator cuff impingement/strain/tear	67 (13.2)	Cardiac-related chest pain/palpitations	24 (22.02)
Arthritis-related pain	62 (12.2)	Facial laceration	15 (13.76)
Back pain/sciatica	48 (9.43)	Contusion/laceration (nonfacial)	11 (10.09)
Calf strain/tear	35 (6.88)	Syncope	10 (9.17)
Knee sprain	31 (6.09)	Head injury	10 (9.17)
Hand/wrist fracture	30 (5.89)	Rib fracture	7 (6.42)
Achilles tendon tear/strain	27 (5.30)	Shortness of breath/dyspnea	6 (5.50)
Meniscus tear	27 (5.30)	Cellulitis	4 (3.67)
Lateral epicondylitis	20 (3.90)	Hernia	3 (2.75)
Plantar fasciitis/rupture	19 (3.73)	Incontinence	2 (1.83)
Hip pain	18 (3.54)	Osteoporosis	2 (1.83)
Ankle sprain	16 (3.14)	Hepatic cyst	1 (<1)
Wrist sprain	15 (2.95)	Oblique strain	1 (<1)
Hand injury	14 (2.75)	Iliac vein stenosis	1 (<1)
Ankle/foot fracture	11 (2.16)	Rhabdomyolysis	1 (<1)
Hip/pelvic fracture	11 (2.16)	Hypertensive emergency	1 (<1)
Hamstring tear/strain	10 (1.96)	Deep vein thrombosis	1 (<1)
ACL or MCL tear	9 (1.77)	Neuropathy	1 (<1)
Shoulder strain/pain (not rotator cuff-related)	8 (1.57)	Periarticular juvenile rheumatoid arthritis	1 (<1)
Neck pain	7 (1.38)	Broken nose	1 (<1)
Foot pain (not fracture or plantar fasciitis)	6 (1.18)	Exertional hyperthermia	1 (<1)
Labral tear	4 (<1)	Subglottic stenosis	1 (<1)
Olecranon bursitis	3 (<1)	COVID-19	1 (<1)
Tibia fracture	3 (<1)	Corneal abrasion	1 (<1)
Pectoralis muscle strain	1 (<1)	Transient vision loss	1 (<1)
Patellar dislocation	1 (<1)	Osteomyelitis and open wound	1 (<1)
Humerus fracture	1 (<1)	Acute kidney injury	1 (<1)
Soft Tissue shoulder mass	1 (<1)	Total	109
Greater tuberosity fracture	1 (<1)
Quadriceps tear	1 (<1)
Shoulder dislocation	1 (<1)
Total	509

a

ACL, anterior cruciate ligament; COVID-19, coronavirus disease 2019; MCL, medial collateral ligament;

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Figure 3.

Pickleball-related injuries categorized according to age group.

Injuries by Provider Type

We also collected information on injuries according to evaluation providers, as well as time for evaluation and follow-up. Overall, patients most commonly were seen by a provider within 1 week of injury (n = 298; 48.2%), with most patients (n = 470; 76%) being evaluated less than a month from the time of injury (Appendix Figure A3). In most injuries (n = 426; 68.9%), patients were initially seen by a nonorthopaedic provider, while for the other 192 (31.1%) injuries, patients were evaluated directly by an orthopaedic or sports medicine specialist (Figure 4). Among the injuries that were initially not evaluated by an orthopaedic provider, 329 (53.2%) were referred to orthopaedics/sports medicine specialists, and in total, 307 (63%) patients saw an orthopaedic or sports medicine provider at some point in the course of treatment for a pickleball-related injury. Further, among patients who saw an orthopaedic specialist, 233 (75.9%) had an additional follow-up visit (>1 appointment) with the specialist for their injury.

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Figure 4.

Initial point of contact for patients evaluated for pickleball-related injuries, 2017-2022.

Injury Evaluation/Treatment

Injury evaluation and treatment varied widely across the study, with medication being the most common treatment modality followed by rest and advanced imaging. A total of 388 (62.8%) injuries were evaluated with at least 1 form of imaging. Among these, radiography was the most common, followed by magnetic resonance imaging and ultrasound. Importantly, 16.7% of patients went on to require surgical intervention for an injury sustained during pickleball (Table 2). Among these surgeries, the most common procedures were arthroscopic (eg, rotator cuff repair, anterior cruciate ligament reconstruction, subacromial decompression; n = 36; 34.9%), followed by open soft tissue repair (eg, Achilles tendon repair; n = 17; 16.5%), and open reduction and internal fixation/intramedullary nail (eg, distal radius fixation; n = 14; 13.6%) (Appendix Table A2).

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Table 2

Subsequent Treatments or Interventions at Vanderbilt University Medical Center for Pickleball-Related Injuries, 2017-2022 ^a

Treatment Category	No. of Injuries (%)
Rest	452 (73.1)
Brace	182 (29.5)
Medication	511 (82.7)
Referral	362 (58.6)
Physical therapy	295 (47.7)
Advanced imaging	388 (62.8)
Radiograph	316 (51.1)
MRI	99 (16)
CT	30 (4.9)
Ultrasound	80 (12.9)
Other (eg, EKG, bronchoscopy)	19 (3.1)
Injection	80 (12.9)
Surgery	103 (16.7)

a

CT, computed tomography; EKG, electrocardiogram; MRI, magnetic resonance imaging.

Discussion

We identified 618 pickleball-related injuries, with a 6.8-fold increase in pickleball injuries throughout the study period. Players <60 years were found to be at higher risk of soft-tissue strain or tear, and players >60 years were at greater risk of fracture. Women were 2 times more likely to sustain a fracture.

As compared with other racket sports—such as tennis ¹⁹ or squash/racquetball ¹⁸ —the age of injury in pickleball is notably older, consistent with the broader demographic trend of the pickleball community. Although pickleball is quickly gaining popularity among younger age groups, the mean age of injury remained relatively steady over the study period. As with other racket sports, the predominance of injuries consisted of soft tissue strain or rupture.^3,4,9,11,15 However, we found a prominent transition in injury patterns with advancing age, characterized by an increased prevalence of fractures and arthritis-related pain. These findings emphasize an age-specific risk profile that could lead to targeted intervention and prevention.

In addition, there were some important sex-based differences in injury patterns. Namely, although most pickleball players were men, women were more likely to sustain pickleball-related injuries. Further investigation into injury types revealed that women were almost twice as likely as men to sustain a fracture from pickleball. Although very little data surrounding pickleball-related injuries exist, 1 preliminary study that investigated pickleball- and tennis-related injuries specifically among older populations found a similar trend. ²⁴ Together, these studies suggest a potential role for interventions such as wrist bracing and medication supplementation that might decrease the risk of fracture, particularly among older women engaging in pickleball.

As expected with sports-related injuries, our study revealed a strong orthopaedic injury burden. The preponderance of musculoskeletal injuries highlights the importance of orthopaedic evaluation in the management of pickleball-related incidents. Moreover, we found a high treatment burden associated with pickleball-related injuries, indicating that while pickleball is generally considered a safe leisurely activity, there is a meaningful risk of the consequent financial and personal impact associated with participation. Together, the overview of the pickleball injury profile and subsequent treatment burden presented in this study can provide valuable insight into injury characteristics and help inform providers’ (both orthopaedic and general practitioner) approach to patient education, diagnosis, treatment, and rehabilitation.

Importantly, although most injuries were orthopaedic, a substantial number of patients initially sought care from nonorthopaedic, particularly primary care providers, emphasizing the pivotal role of general practitioners in the early stages of injury management and the necessity for a multidisciplinary approach to pickleball-related injuries. Given the broad presentation pattern of patients in this study, both orthopaedic specialists and primary care providers need to be equipped to educate and deliver care for persons engaged in this increasingly popular sport. Furthermore, we found a high level of treatment burden (assessment time, diagnostic workup, surgical intervention, follow-up, etc) associated with pickleball-related injuries. Thus, treating pickleball-related injuries not only has personal risks for the patient but also a potentially dramatic financial impact.

Notably, although older individuals are often drawn to the sport's social and low-impact attributes, our findings indicate a meaningful risk of injury associated with pickleball, particularly among this age group. Moreover, the injury patterns shift with age, wherein the prevalence of fractures and arthritis-related pain increases with age. Decreasing balance and coordination, coupled with increasing injury risk in this population appears to be a detrimental combination. Patients should be counseled to approach the sport slowly, learn about technique, and improve strength, flexibility, and balance before participation. The evolving risk profile as players transition into different stages of life suggests that future investigations are warranted into targeted interventions, especially in older patients, that could potentially mitigate this risk.

Last, while this study highlighted the potential risks of pickleball, there are many benefits to pickleball participation—including physical, mental, and social. In a recent review, Stroesser et al ²² reported that pickleball participation was associated with greater life satisfaction, decreased rates of depression, and improved psychological well-being across all age groups, particularly among older participants. These mental health benefits are partially attributed to the increased social connection associated with pickleball participation, wherein seniors participating in pickleball reported lower rates of loneliness and a greater sense of social integration and interaction. ⁷ Moreover, while less established than the psychological and social benefits, pickleball participation has also been associated with improvements in physical health such as up to 3000 increased steps per day, increased caloric expenditure, and cardiovascular benefits (eg, decreased systolic blood pressure and decrease in coronary artery disease). ²¹ Together, these studies highlight the many benefits of pickleball participation—particularly in older populations—and underscore the importance of weighing the potential risks outlined in this study against these benefits.

Conclusion

We observed a 6.8-fold increase in pickleball-related injuries at our institution from 2017 to 2022, which far outpaces the reported increase in pickleball participation nationally. Women >60 years were found to be at the highest risk of injury and were more likely to sustain fractures. Most injuries were musculoskeletal related, with soft tissue injury occurring most commonly in patients <60 years and fractures more common in those >60 years.