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

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 SPORT-SPECIFIC ILLNESS AND INJURY

Pickleball: Review and Clinical Recommendations

for this Fast-growing Sport
Kenneth Vitale, MD, FACSM1 and Steven Liu, BS2
Downloaded from http://journals.lww.com/acsm-csmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/01/2021

Pickleball is now being taught in mid-

Abstract dle and high school physical education
Pickleball is a single or doubles volley sport played with paddles and ball on classes and has gained popularity with
a hardcourt. Growing in popularity in recent years, injuries can occur similar masters athletes, older adults, and retire-
to racquet sports; however, there is a scarcity of references in the literature ment centers (8,9) because of its social
for sports medicine providers encountering these athletes and injuries. This features (10). However, little is published
review provides clinicians treating pickleball athletes with an overview of on pickleball injuries. In fact, a PubMed
the sport, a case study demonstrating the significant injuries that can occur search on “pickleball” retrieved no reviews
in pickleball, and a review of the available literature. We provide a discussion or cases, and only one editorial. Tradition-
on common pickleball injuries, injury prevention strategies, and event cover- ally, some players may consider pickleball
age recommendations to better equip sports medicine providers with a base a “milder” sport in comparison to tennis,
of knowledge and a clinical approach to treat these athletes, or “picklers,” because it is on a smaller court with less
who enjoy this fast-growing sport. running, uses a small paddle, and uses
lower ball strike velocities, and thus may
not be viewed as a high injury-risk sport.
Introduction This perception may be because of the fact that it can be quite
Pickleball is a paddle sport that is gaining popularity in re- a social sport (similar to adult casual softball leagues), often with
cent years. Typically played on a 20  44-ft court with a vol- quirky nicknames for teams (and the sport itself, many have
ley zone in the middle (Fig. 1), the sport could be considered a misperceived the game as “prickleball,” “pick-a-ball,” “pickle
combination of tennis, badminton, wiffleball, and table tennis pong,” and others). Further contributing to this perception
(1). Singles or doubles compete using a plastic ball and a pad- may be its popularity and association with the older adult
dle (Fig. 2). The game begins with an underhand serve, and and retirement community (8,9). However, in the author's
volleys proceed similar to tennis (Fig. 3). Pickleball's growth (K.V.) clinical experience, there are many injuries that occur
could be because of its universal appeal: the rules are simple, with pickleball, and injuries can be similar in severity to other
and the game is easy to play for beginners but can quickly de- team sports. The popularity of pickleball and varying experi-
velop into a fast-paced competitive match for experienced players. ence with pickleball injuries among providers may be because
Both younger and older adults are drawn to the sport, and there of the geographical disparities, because pickleball has seen
are plentiful opportunities to play, such as open play and leagues more growth and new court construction in the Southern
at local recreational centers. There is even a national governing United States (10).
body for Pickleball in the United States, which considers pickleball We present an interesting case report of a pickleball injury
as “one of America's fastest-growing sports” along with multiple and review the available literature on pickleball. To our knowl-
media sources (2–5). In 2016, there were 2.5 million participants edge, there are no reported cases or reviews on injuries; this is
(6), and according to the Sports and Fitness Industry Association's the first review to provide clinicians with an overview of the
2018 report, there are now 3.1 million participants in the United pickleball game, give clinical recommendations on pickleball
States alone (a 12% increase from 2017) (7). injuries, and raise awareness to the possibility of significant in-
jury while playing what some may consider a low-impact/low-
1
Department of Orthopedic Surgery, Division of Sports Medicine, University risk sport. Providers need to be aware of the increasing variety
of California San Diego School of Medicine, La Jolla, CA; and 2School of
of alternative sports available to the general population and the
Medicine, Eastern Virginia Medical School, Norfolk, VA
growing participation especially in masters athletes and older
Address for correspondence: Kenneth Vitale, MD, FACSM, Department of adults as the baby boomer generation ages (11). Older adults
Orthopedic Surgery, University of California San Diego, 9300 Campus Point are at risk for injury both in sport and from falls in the commu-
Drive, #7894, La Jolla, CA 92037-1398; E-mail: kvitale@health.ucsd.edu. nity (12,13), and clinicians should have a low threshold for
1537-890X/1910/406–413
further workup and treatment of a musculoskeletal complaint,
Current Sports Medicine Reports even with apparently low-risk sports participation, such as
Copyright © 2020 by the American College of Sports Medicine pickleball.

406 Volume 19  Number 10  October 2020 Pickleball Injuries

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Figure 1: Pickleball court dimensions (illustration by Kenneth Vitale, MD, FACSM).

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 de-
nied 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 pos-
terior thigh. Physical examination was notable for ischial tu-
berosity and proximal posterior thigh tenderness, pain with
resisted leg press and straight leg hip extension. Based on clini-
cal presentation a likely hamstring strain was suspected. X-rays
were negative for fracture but did show a small area of ossifica-
tion 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 addi-
tion, there was a full-thickness, full-width tear of the left ad-
ductor magnus tendon at its ischial attachment with distal

Figure 2: Pickleball paddle and ball (photo courtesy of Steven Liu). Figure 3: Adults playing pickleball (photo courtesy of Steven Liu).

www.acsm-csmr.org Current Sports Medicine Reports 407

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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).

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.
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 reason-
able 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 thick-
ness, 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 imbal-
ances 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

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).

408 Volume 19  Number 10  October 2020 Pickleball Injuries

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
are no reported cases of a combination full thickness near
full-width hamstring tear (with avulsion), plus a complete ad-
ductor magnus tear (without avulsion), further outlining not
only the anatomical uniqueness of this injury but also the sever-
ity 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 ad-
ductor 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 ad-
ductor longus is more commonly mentioned in cases of an ad-
ductor 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 aponeuro-
sis with supporting fibrous expansion to its insertion, the ad-
ductor 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 publi-
cations 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 or-
igin 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 func-
tions in hip extension (20). This tendinous origin has a similar in-
nervation 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 impli-
cations 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 inci-
dence 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 litera-
ture. A literature search was initiated to further explore this
sport and its associated injuries.
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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 psychologi-
cal aspects of why older adults play pickleball but not on med-
ical 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 ref-
erences 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 actu-
ally 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 opti-
mizing 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 inves-
tigated the psychological connection to pickleball in older
(>55 years) adults in four distinct connection levels of aware-
ness, 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 fit-
ness 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 con-
cluded that pickleball can be an enriching recreational activity
that can additionally help with coping as individuals transi-
tion into retirement and improve life satisfaction (29). The last
article pointed out that many enjoy pickleball because it sat-
isfies 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 Elec-
tronic Injury Surveillance System (NEISS) (31). The NEISS ob-
tains a probabilistic sample to estimate national injury incidence
(31). However, certain subgroup data were considered unstable
Current Sports Medicine Reports 409
and potentially unreliable, and the study mentioned that these es-
timates 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 inju-
ries 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 clin-
ical experience with pickleball injuries discussed in the next sec-
tion. 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 tour-
naments and open-play include typical overuse injuries, such as
knee (meniscal pathology, patellar tendinopathy, medial collat-
eral ligament strains, and osteoarthritis flares), shoulder condi-
tions (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 com-
mon in women, whereas lower-limb injuries (knee, ankle, thigh,
calf) are more common in men (32,33). Acute injuries tend to af-
fect 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 lacera-
tions as older athletes. Racquet sports are considered high risk
for eye injuries, which can be serious and may result in hospital-
ization, 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 demo-
graphic 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 recommenda-
tions 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
410 Volume 19  Number 10  October 2020
Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
include maximizing shoulder range of motion and quadriceps ac-
tivation 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 includ-
ing sunscreen, lip balm, sunglasses, and hat or sports visor.
During the heat of the summer in our region, adequate hydra-
tion and electrolyte repletion according to recognized guide-
lines (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 reduc-
tion. 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 sta-
ble 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 sud-
den 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 back-
pedaling 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 popu-
lation 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 rehabilita-
tion 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
Pickleball Injuries
Figure 6: Taping and bracing options often used by picklers (photo courtesy of Steven Liu).
tennis matches in tournament play may last 2 h to 4 h (46).
Pickleball players may refer to these values in tennis when con-
sidering their length of play.
Pickleball equipment
Similar to the above sections, because of the lack of pub-
lished studies in pickleball, there are no evidence-based recom-
mendations 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 ade-
quate 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 recom-
mend 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 eas-
ily 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 poten-
tially influence injury risk. In addition, protective taping and
bracing of wrists and ankles may prove useful (Fig. 6), espe-
cially 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 ap-
proved polybicarbonate impact-resistant sports glasses (Fig. 7).
Masters athletes and older adults are recommended exer-
cise 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 fre-
quent rest periods for pickleball. Practical advice for older
adults who often exercise with multiple chronic orthopedic
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Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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 tour-
nament 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 medi-
cal 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 flexibil-
ity for medical evaluation and rest periods for older adult
participants. Protective eyewear (Fig. 7) and court shoes (not
Figure 7: Impact-resistant polybicarbonate sports glasses (illus-
tration by Kenneth Vitale, MD, FACSM).
Current Sports Medicine Reports 411
running sneakers) should be highly recommended in all picklers
due to risk of injury (25,36,44). Mobile phones have largely re-
placed two-way radios and walkie-talkies for event staff com-
munication; 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 partic-
ularly risky for exertional heat illness and staff should be pre-
pared. 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 condi-
tions. 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 equip-
ment (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 suc-
cumb 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 com-
munication, 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 medi-
cine 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 na-
tional 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 espe-
cially 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 pro-
viders treating these athletes, to equip clinicians with the tools
412 Volume 19  Number 10  October 2020
Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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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