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Sport-specific Illness and Injury

Pickleball: Review and Clinical Recommendations for this Fast-growing Sport

Vitale, Kenneth MD, FACSM1; Liu, Steven BS2

Author Information
Current Sports Medicine Reports: October 2020 - Volume 19 - Issue 10 - p 406-413
doi: 10.1249/JSR.0000000000000759
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Introduction

Pickleball is a paddle sport that is gaining popularity in recent years. Typically played on a 20 × 44-ft court with a volley zone in the middle (Fig. 1), the sport could be considered a combination of tennis, badminton, wiffleball, and table tennis (1). Singles or doubles compete using a plastic ball and a paddle (Fig. 2). The game begins with an underhand serve, and volleys proceed similar to tennis (Fig. 3). Pickleball's growth could be because of its universal appeal: the rules are simple, and the game is easy to play for beginners but can quickly develop into a fast-paced competitive match for experienced players. Both younger and older adults are drawn to the sport, and there are plentiful opportunities to play, such as open play and leagues at local recreational centers. There is even a national governing body for Pickleball in the United States, which considers pickleball as “one of America's fastest-growing sports” along with multiple media sources (2–5). In 2016, there were 2.5 million participants (6), and according to the Sports and Fitness Industry Association's 2018 report, there are now 3.1 million participants in the United States alone (a 12% increase from 2017) (7).

Figure 1
Figure 1:
Pickleball court dimensions (illustration by Kenneth Vitale, MD, FACSM).
Figure 2
Figure 2:
Pickleball paddle and ball (photo courtesy of Steven Liu).
Figure 3
Figure 3:
Adults playing pickleball (photo courtesy of Steven Liu).

Pickleball is now being taught in middle and high school physical education classes and has gained popularity with masters athletes, older adults, and retirement centers (8,9) because of its social features (10). However, little is published on pickleball injuries. In fact, a PubMed search on “pickleball” retrieved no reviews or cases, and only one editorial. Traditionally, some players may consider pickleball a “milder” sport in comparison to tennis, because it is on a smaller court with less running, uses a small paddle, and uses lower ball strike velocities, and thus may not be viewed as a high injury-risk sport. This perception may be because of the fact that it can be quite a social sport (similar to adult casual softball leagues), often with quirky nicknames for teams (and the sport itself, many have misperceived the game as “prickleball,” “pick-a-ball,” “pickle pong,” and others). Further contributing to this perception may be its popularity and association with the older adult and retirement community (8,9). However, in the author's (K.V.) clinical experience, there are many injuries that occur with pickleball, and injuries can be similar in severity to other team sports. The popularity of pickleball and varying experience with pickleball injuries among providers may be because of the geographical disparities, because pickleball has seen more growth and new court construction in the Southern United States (10).

We present an interesting case report of a pickleball injury and review the available literature on pickleball. To our knowledge, there are no reported cases or reviews on injuries; this is the first review to provide clinicians with an overview of the pickleball game, give clinical recommendations on pickleball injuries, and raise awareness to the possibility of significant injury while playing what some may consider a low-impact/low-risk sport. Providers need to be aware of the increasing variety of alternative sports available to the general population and the growing participation especially in masters athletes and older adults as the baby boomer generation ages (11). Older adults are at risk for injury both in sport and from falls in the community (12,13), and clinicians should have a low threshold for further workup and treatment of a musculoskeletal complaint, even with apparently low-risk sports participation, such as pickleball.

Case Report

A 71-year-old male pickleball player presented in January 2019 with 1 month of left posterior thigh pain. He was an avid pickleballer for years, accustomed to the sport and denied history of major orthopedic injury. He did not recall a specific inciting event other than during the match while returning a volley, he felt a sharp posterior thigh pain and a popping sensation, pointing to the buttock and proximal posterior thigh. Physical examination was notable for ischial tuberosity and proximal posterior thigh tenderness, pain with resisted leg press and straight leg hip extension. Based on clinical presentation a likely hamstring strain was suspected. X-rays were negative for fracture but did show a small area of ossification in the proximal hamstring in which the radiologist could not rule out avulsion. Further workup with magnetic resonance imaging (MRI) was therefore recommended to better assess for avulsion fracture and extent of hamstring tear. The MRI showed a full-thickness, near-full width tear of the left hamstring tendons at their ischial attachment with retraction of the torn fibers and a 1.1-cm avulsed bone fragment, leaving a 4.3-cm fluid-filled gap (Fig. 4). A few intact anterior fibers of the semimembranosus tendon were present. Interestingly, in addition, there was a full-thickness, full-width tear of the left adductor magnus tendon at its ischial attachment with distal retraction of the torn fibers, leaving a 1.5-cm fluid-filled gap (Fig. 5). Because of the uniqueness and extent of his injury, he was referred to an orthopedic surgeon for consultation.

Figure 4
Figure 4:
MRI coronal T2 image demonstrating full-thickness, near full width tear of the left hamstring with retraction, 1.1-cm avulsed bone fragment and 4.3-cm fluid-filled gap (photo courtesy of Kenneth Vitale, MD, FACSM).
Figure 5
Figure 5:
MRI coronal T2 image showing full-thickness, full-width tear of the left adductor magnus tendon with retraction and 1.5-cm fluid-filled gap (photo courtesy of Kenneth Vitale, MD, FACSM).

Upon further discussion with the surgeon, he later disclosed that he did have some antecedent symptoms; therefore, this may have been an acute on chronic injury. While he was quite symptomatic at initial presentation, he did improve over the next 2 months and was able to walk without pain and only had mild discomfort with sitting. Surprisingly, he had reasonable strength on examination at 2 months postinjury. During discussion of surgical options, he understood surgery was somewhat time-sensitive for his injury, but upon consideration of all options, he opted for nonsurgical management. At last follow-up, he was proceeding with physical therapy, and if symptoms persisted, the plan was for a repeat MRI and possible surgical intervention. He was able to return to basic activities, but not competitive pickleball.

Case Discussion

This case is unique because it presents an uncommon injury combination: an avulsion fracture with full thickness, near full-width hamstring tear, and a quite significant full thickness, full-width adductor magnus tear, but without avulsion. Hamstring tears are very common in sports, and injuries may occur because of a number of factors, including strength imbalances between the hamstrings and quadriceps, muscle tightness, muscle fatigue, and/or poor conditioning (14–17). Avulsion fractures occur often with trauma; however, typically, ischial tuberosity avulsions are often reported in younger patients and in more high-energy trauma (18). To our knowledge, there are no reported cases of a combination full thickness near full-width hamstring tear (with avulsion), plus a complete adductor magnus tear (without avulsion), further outlining not only the anatomical uniqueness of this injury but also the severity of an injury that may occur with pickleball.

Adductor Magnus Tears and the Adductor Magnus “Mini Hamstring”

Although a powerful adductor of the thigh, the adductor magnus can be considered a part of the hamstrings because of the similar embryogenesis, innervation and blood supply in part, and contribution to hip extension (19,20). Typical adductor magnus mechanisms of injury can be similar to the hamstrings and include strong eccentric contraction and/or sudden change in direction with forced adduction against an abducting force (19,21). Unlike the hamstring, full thickness adductor magnus tears are uncommon in sport, and the adductor longus is more commonly mentioned in cases of an adductor strain, or “pulled groin” (21). There are cases of partial adductor magnus tears with high-impact sports (e.g., football, soccer, and basketball in the author's experience). However, because of its wide footprint on the pelvis, thick and fleshy muscular rather than tendinous origin, and broad aponeurosis with supporting fibrous expansion to its insertion, the adductor magnus is less commonly injured (20,21) and complete tears are not well reported in the literature. In fact, a PubMed search in July 2019 for “adductor magnus tear” yielded only two results and “adductor magnus rupture” four results, and only two were actual proximal tears (most were distal conditions or vascular cases). There are numerous publications on ischial tuberosity avulsions and adductor longus tears, however not on proximal adductor magnus tears, further demonstrating the distinctiveness of this case.

In recent years, a better appreciation of the anatomy is emerging. Separate from the well-reported conjoint and semimembranosus tendon origins, the adductor magnus origin has received less attention (20). While the pubofemoral muscular origin contributes to most of the adduction, the smaller ischiocondylar origin is tendinous rather than muscular and functions in hip extension (20). This tendinous origin has a similar innervation and function to the hamstrings, and some consider it part of the hamstring complex, referring to it as the adductor magnus mini hamstring (AMMH) (20–24). The AMMH is a source of diagnostic confusion even among radiologists in cases of presumed complete conjoint and semimembranosus tears, often misunderstood as partially intact residual fibers of a partial attenuated semimembranosus (20). The AMMH is uncommonly completely torn, found in only 6% of cases (20). This is a significant finding with important clinical implications not only for radiologists to achieve the proper diagnosis but also surgeons for accurate anchor placement during repair to maximize postoperative function. Ultimately, the true incidence of these injuries remains unknown, as athletes may play through partial tears and minor strains. Cases of adductor magnus tears, whether the pubofemoral adductor magnus or the AMMH, may go underreported.

This injury occurred in an older adult while playing pickleball, a sport that has drawn little attention in the scientific literature. A literature search was initiated to further explore this sport and its associated injuries.

Literature Review

A PubMed search in December 2019 without language, date, or article type restrictions containing “pickleball” yielded four results; “pickle ball,” two nonrelevant results; and “pickle-ball,” 0 results. Four published articles exist on pickleball: one a brief editorial narrative (Q&A format) about caring for pickleball injuries (25), two articles explaining the psychological aspects of why older adults play pickleball but not on medical injuries (26,27), and one on pickleball injuries treated in emergency departments (28). Additional expanded search of the National Center for Biotechnology Information databases, including the National Library of Medicine Catalog and PubMed Central, Google Scholar, and manual searching of references of the above retrieved articles, yielded 14 more articles which were screened, with only one being relevant. A narrative review of the relevant articles was performed as follows.

The editorial was the first article that mentioned injuries (25). In this narrative, the author discussed pregame warm-up exercises and stretches, emphasized importance of protective eyewear and appropriate athletic shoe/sneaker use, and the option for wrist and ankle bracing. The author had played pickleball and proposed that common injuries are often actually preexisting injuries that recur or present as injuries similar to racquet sports (25). The author also reviewed various lay/consumer pickleball web sites and outlined the commonly mentioned injuries, including sprains and strains, tendinopathy, plantar fasciitis, rotator cuff injuries, distal extremity fractures, and head/facial trauma, including orbital trauma. Lastly, the author emphasized the value of frequent rest breaks and optimizing hydration.

There were three studies that discussed the psychosocial and well-being aspects of the sport. While not injuries, they reveal important points for any medical provider regarding patient health, longevity, and quality of life. One study investigated the psychological connection to pickleball in older (>55 years) adults in four distinct connection levels of awareness, attraction, attachment, and allegiance (26). They found that the highest connection levels occurred in those who played pickleball for at least 1 year and at least 10 times a month. Although the most important motives to play were fitness and socialization, competition and skill mastery also were viewed as significant reasons for play (26). Another study examined experiential factors, such as life satisfaction, optimism, and social integration, in the demographic that plays in pickleball tournaments (29). Life satisfaction varied with age and employment status. The oldest pickleball players (70+ years) were more likely to be satisfied with life than the younger players (50 to 59 and 60 to 69). Retirees were more satisfied than employed counterparts. Women were more likely to experience social integration than men. They concluded that pickleball can be an enriching recreational activity that can additionally help with coping as individuals transition into retirement and improve life satisfaction (29). The last article pointed out that many enjoy pickleball because it satisfies certain needs in older adults, including competition and ongoing development of personal mastery (30).

There is a single publication on pickleball injuries treated in emergency departments based on data from the National Electronic Injury Surveillance System (NEISS) (31). The NEISS obtains a probabilistic sample to estimate national injury incidence (31). However, certain subgroup data were considered unstable and potentially unreliable, and the study mentioned that these estimates should be evaluated with caution. They estimated 19,012 pickleball injuries in a 17-year period, with an increase each year in the last 5 years of the study. The mean age was 63 years, with 90.9% of the injured being 50 years or older, and 50.4% were men. The most common injuries were strain/sprain (28.7%) and fracture (27.7%), followed by contusion/abrasion (11.9%) and laceration (5.9%). Although these injuries only reflect conditions that led to an emergency department visit and may not represent the most common injuries in the general pickleball population, they are fairly similar to our clinical experience with pickleball injuries discussed in the next section. Lower extremity (32%) and upper extremity (25.4%) were fairly even, with trunk (21.4%) and head/neck (16.9%) less common.

Clinical Recommendations

In the author's (K.V.) experience, the most common pickleball injuries seen in our (Southern California) local and regional tournaments and open-play include typical overuse injuries, such as knee (meniscal pathology, patellar tendinopathy, medial collateral ligament strains, and osteoarthritis flares), shoulder conditions (rotator cuff tendinopathy), lateral epicondylitis, Achilles tendonitis, and plantar fasciitis. Less prevalent, but still common, include low back pain exacerbation and hamstring and/or groin strain. Common acute traumas include wrist and finger fractures and low ankle sprains. These are similar to racquet sports, which report elbow and lower back as the most common injury, followed by knee and shoulder (32). Women have a higher injury incidence (32,33); the shoulder, foot, and wrist are most common in women, whereas lower-limb injuries (knee, ankle, thigh, calf) are more common in men (32,33). Acute injuries tend to affect lower extremities, whereas chronic injuries usually involve the upper extremities (34). Muscle injuries are most frequent; however, stress fracture incidence is increasing in recent years (33). Younger athletes (<18 years) sustain twice as many fractures (35) as older athletes. Besides musculoskeletal injuries, lacerations also occur and are most common in the head/neck region (30); younger athletes have three times as many lacerations as older athletes. Racquet sports are considered high risk for eye injuries, which can be serious and may result in hospitalization, surgery, and permanent vision loss (36). Treatment of these conditions also is documented (34) and is not markedly different with pickleball, other than the participation demographic which may include older adults who can recover more slowly from injury than their younger counterparts (37,38).

Injury Prevention

Pregame warm-up

We agree with the abovementioned strategies of pregame warm-up. There are no published references or recommendations for a pickleball-specific warm-up. In our experience, most players (if experiencing symptoms due to lack of proper warm-up) typically report shoulder pain with volleys and knee pain with short starts and stops to the net. Therefore, we suggest referring to published data on rotator cuff activation exercises in other overhead sport warm-ups, for example, the Thrower's Ten program (39). Pickleball athletes also may consider warm-up recommendations from the USA Pickleball Association (USAPA) and the Pickleball Canada Organization (40,41), which include maximizing shoulder range of motion and quadriceps activation exercises prior to playing. The only reference we found specifically regarding warm-up in racquet sports related to injury, mentioned a dynamic full-body warm-up, adequate range of motion, and shoulder capsular stretching prior to commencing racquet-related activity or an interval tennis program (42).

In addition to a general warm-up, a sport-specific warm-up, such as a quick game of “skinny singles” to practice dinks, volleys, and serves, may improve performance, but because of the lack of studies, we cannot say if this may reduce risk of injury. In Southern California, many games are played on outdoor courts, and appropriate sun protection also is essential including sunscreen, lip balm, sunglasses, and hat or sports visor. During the heat of the summer in our region, adequate hydration and electrolyte repletion according to recognized guidelines (43) are paramount because pickleball tournaments may last several hours. Observe usual outdoor precautions, such as games on wet courts after rain, and being attentive of bare spots or cracks in the playing surface (which may be especially important in older adults with less visual acuity, impaired proprioception, and risk of fall). Besides net posts and other fixtures, sometimes benches or even gym equipment may be close to the court, and athletes risk contact and blunt trauma injuries (44).

Sport-specific training

In regard to pickleball-specific movements, based on our experience, we can provide suggestions; however, there are no published studies as of yet demonstrating injury risk reduction. Learning the pickleball split step may be sound advice to get accustomed to the “ready position” or the familiar athletic position common in multiple sports. This keeps your feet stable and weight balanced, reducing risk of the athlete “wrong footing” themselves and getting an ankle sprain, or worse, a fall and possible fracture. In sprints toward the nonvolley zone (NVZ) (Fig. 1), athletes are encouraged to be careful with sudden stops during avoidance of stepping “into the kitchen” (NVZ); these forceful eccentric stops can be a risk factor for lower-extremity musculotendinous tears and ankle sprains. Having the ball contact point behind your body forces undue biomechanical stress and overcompensation. Keeping the contact point in front of your body is more biomechanically appropriate and reduces musculoskeletal stress. Avoid backpedaling on the heels to return a lob shot that goes over a player's head; this is all too common in older adults who have less physical agility to quickly turn and run toward the ball. Impaired balance and proprioception in the older adult population further risk falls, fractures, and possible head trauma. In the event of a fall, learning to fall (“going with it” to picklers) and roll with the momentum rather than forcefully extending the hand may reduce upper-extremity injuries when trying to break a fall. If recovering from a shoulder condition, for example, rotator cuff injury, we recommend avoiding “put away” shots and overhead smashes in the initial rehabilitation period. Fortunately, all serves in pickleball begin with the underhand serve, benefitting athletes with acute or chronic shoulder conditions.

Regarding length of play, there are no published guidelines regarding optimal frequency and duration to avoid injury in racquet sports. Studies suggest that typical “two sets to win” tennis matches may average 1.5 h (45) while some studies of tennis matches in tournament play may last 2 h to 4 h (46). Pickleball players may refer to these values in tennis when considering their length of play.

Pickleball equipment

Similar to the above sections, because of the lack of published studies in pickleball, there are no evidence-based recommendations regarding equipment, so what we present is based on our experience treating athletes. Proper court shoes are a must with pickleball; running sneakers do not provide adequate nonsagittal plane motion support because these are sneakers designed for linear movements. Court shoes also have better tread “give” and “stick to the court” less (44), which may lessen ankle sprain risk. Based on our experience, we recommend athletes consider starting with the continental neutral grip on the paddle rather than Eastern or Western grips and adjust as skill level increases to avoid wrist injuries and epicondylitis. Many novice picklers grip the paddle too tightly and risk epicondylitis “tennis elbow” flares (“pickleball elbow” among picklers). Many novice players also tend to choose a heavier paddle than what they should be using and get pickle elbow this way (even with seemingly small changes such as an 8.5 oz paddle vs a lighter 7.2 oz). The pickleball paddle does not easily allow a two-handed stroke like the tennis backhand, so a heavier paddle may quickly result in epicondylitis. Getting used to the different pickleballs used, such as the faster and harder outdoor balls versus the softer and slower indoor balls also is important, because the speed of game play may potentially influence injury risk. In addition, protective taping and bracing of wrists and ankles may prove useful (Fig. 6), especially in those with prior injury and chronic joint instability. As pickleball involves hitting a hard polymer ball at speeds up to 30 mph to 40 mph, protective eyewear is recommended not only for protection from the ball but also the partner's (or even player’s own) paddle. Athletes with glasses should use approved polybicarbonate impact-resistant sports glasses (Fig. 7).

Figure 6
Figure 6:
Taping and bracing options often used by picklers (photo courtesy of Steven Liu).
Figure 7
Figure 7:
Impact-resistant polybicarbonate sports glasses (illustration by Kenneth Vitale, MD, FACSM).

Masters athletes and older adults are recommended exercise according to the same guidelines as the general population (47), but a few precautions are worth mentioning. Older adults should exercise at similar intensities as younger populations, but may require a longer warm-up, recovery, and more frequent rest periods for pickleball. Practical advice for older adults who often exercise with multiple chronic orthopedic conditions include following the classic “pain rules” to exercise participation, such as pain that worsens with activity, persists for >24 h after activity, or causes a gait change should alert the athlete to modify activities and/or seek medical attention (48). These sensible, real-world recommendations are easy to understand by the older adult pickler. Also, the concept of “prehabilitation” is gaining strength in recent years as a way to possibly prevent sports injury and is a worthy topic to discuss with older adult athlete populations. Prehabilitation is an exercise conditioning program designed to improve both fitness and function prior to engaging in a high injury risk sport or in those deconditioned in attempt to reduce injury (49,50).

Event Coverage

For providers who wish to provide pickleball game or tournament coverage, there are several suggestions. Basic game coverage is similar to other racquet sports and has been reviewed previously in this journal (51). Since many older adults play pickleball (8,9,47,48), discussions with the event director should include enough time in scheduling for adequate medical time-outs and avoiding excessive games in succession due to fatigue and injury risk in masters athletes (11,13). Many local pickleball tournaments fortunately do not have as strict of a tournament structure as tennis, and likely have more flexibility for medical evaluation and rest periods for older adult participants. Protective eyewear (Fig. 7) and court shoes (not running sneakers) should be highly recommended in all picklers due to risk of injury (25,36,44). Mobile phones have largely replaced two-way radios and walkie-talkies for event staff communication; most pickleball tournaments occupy a smaller court footprint compared with other sports (e.g., multicourt tennis domes), and phones may not be as critical in these events. Pickleball is often outdoors, during the summer, and popular in the Southern United States (10); this combination can be particularly risky for exertional heat illness and staff should be prepared. Most older athletes are often playing with several chronic conditions (e.g., osteoarthritis, tendinopathy, chronic low back pain), and medical providers should be aware of pain exacerbations of these common musculoskeletal conditions. Medical tent setup overall is similar to any other routine event coverage, with the recommendations of additional ice packs and ice baths for heat illness, tape and wrist and ankle braces (Fig. 6) for flares of chronic conditions and routine sprains and strains, and eye assessment and treatment equipment (e.g., fluorescein dye, eye patch, etc.).

In conversation with the USAPA director of competitions, the USAPA staff reiterates similar experiences as above, namely, that at USAPA tournaments, the most common conditions seen in players are mainly heat exhaustion and preexisting injuries. The director cautions all picklers to properly hydrate; in their experience, the older adult often is not familiar with electrolyte replacement, thinking water is enough. Many do not do adequate warm-up, and yet picklers often play 6 h·d−1 and succumb to muscle strains, tightness, and dehydration. Even when playing indoors, they have seen many players not hydrating enough and suffering exertional heat illness (K.V. author communication, unpublished).

Some sports medicine providers may not know that there are major pickleball events, such as the USAPA National Championships, Pickleball US Open, and World Pickleball Open, to name a few. At sanctioned events, nationals, some regionals and high-level local tournaments, there are sports massage therapists, physiotherapists, and emergency medical technician/paramedic personnel, but often no physician on-site. These may be excellent opportunities for a sports medicine clinician to provide event coverage and serve as a team physician for this growing sport. The USAPA encourages sports medicine providers to contact them if interested; the national championships are every year at Indian Wells, CA, and they welcome attendees. Although it continues to grow, USAPA does not yet have a formal sports science department dedicated to injury assessment like other major sports associations; this represents another opportunity for the field of sports medicine and exercise science to collaborate and provide services to the world of pickleball.

Conclusions

Pickleball is a fast-growing sport, gaining popularity especially in the masters athlete and older adult populations. We present a case study that represents one of several common injuries that may occur with pickleball and demonstrates the potential severity of pickleball injuries. Sports medicine clinicians need to be aware of this developing sport and its potential injuries on both younger and older populations. We provide an overview of the sport, typical injuries, clinical recommendations, and injury prevention approaches for providers treating these athletes, to equip clinicians with the tools necessary to better serve the population of “picklers” playing this fun and growing sport.

A sincere thanks to Alpha Anders (University of California San Diego School of Medicine) for his kind assistance with manuscript preparation.

The authors declare no conflict of interest and do not have any financial disclosures.

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