July 24, 2023 – Pickleball.
It's a latest national obsession, the fastest-growing sport within the U.S. And by the tip of 2023, pickleball is predicted to generate about 67,000 emergency room visits, 366,000 outpatient visits, 8,800 outpatient surgeries, 4,700 hospitalizations and 20,000 post-acute injury episodes. In total, financial analysts at UBS Group AG have forecast that direct medical costs for pickleball will exceed $377 million this 12 months alone, primarily as a result of wrist, lower leg, head or lower trunk injuries.
Why is one of the crucial popular and accessible sports related to falls, tears, strains and sprains? And more importantly, what can pickleball players (also called “picklers”) – especially those over 60 – do before playing to stop injury and avoid a visit to the emergency room?
Safety begins with risk perception.
“It's a weird name, it lulls you into a sense of security and increases your risk of injury,” says Joshua S. Dines, MD, a sports medicine physician on the Hospital for Special Surgery in New York City and medical director of Major League Pickleball.
Felice de Jong, PhD, a 67-year-old scientist who lives in Nellysford, VA, explained that when she first heard the name “pickleball,” she thought it might be “a piece of cake, like playing tiddlywinks.” Being energetic all her life, she dove right into the sport after just a couple of hours, badly sprained her ankle, developed tennis elbow, and needed to rest her racquet for several weeks before she could return to the court.
Her advice to others is straightforward: play at your personal risk.
“Despite the name, a certain level of general fitness is required. If you are not fit, don't play because you will get injured,” said de Jong.
For those that don't know, pickleball is form of a hybrid of tennis, badminton, and table tennis. It's played on a badminton-sized court, has a net, uses a racket as a substitute of a racquet, and accommodates a plastic ball with holes in it.
Bill Edelman, 67, a retired medical technician who splits his time between Boston and Florida, said pickleball could also be less physically demanding, nevertheless it's still a sport.
“Respect your age,” he said. “You are not a 20-year-old playing this game; you are your age you're playing the game at. The problem is that unless you have some experience playing the game (and I'm by no means an expert), you should be a little more respectful of the fact that you're trying something new.”
Edelman, who tore a meniscus in his knee early in his pickleball career, said he didn't even realize he was constantly tripping over his own feet or thinking about stepping on his shoelaces because he didn't know how to stand properly.
“It caused me to fall,” he said.
Lulled into complacency
During the pandemic, pickleball was an entry point into the activity, especially for people in their 60s and 70s, many of whom were forced into retirement or chose to do so when businesses went bankrupt or laid off employees. It quickly became a seemingly harmless solution to the mandatory lockdowns, allowing people to meet and socialize outdoors. It was also addictive; over the past 3 years, pickleball participation has skyrocketed almost 159%it has become a globally recognized professional sport and is increasingly attracting younger players in their twenties and thirties. It is even taught in middle and high schools.
But as with many other training trends, the road to pickleball is often paved with minefields. In this case, the dangers begin with overuse injuries, inflamed, painful tendons (tendinitis), and chronic tendon problems.
“People are on the market for 4 or five hours, rotating and twiddling with different people,” Dines said. “And they're potentially exposing themselves to more overuse injuries just by the quantity of hours they spend.”
Dines said he has suffered a variety of injuries over the past few years, ranging from torn meniscuses in his knee and back pain (mainly from side-to-side movement, bending over and lunging) to rotator cuff inflammation and tennis/golfer's elbow.
Some of these injuries (especially to the knee) can be serious.
“A majority of pickleball players are older adults over 50 and 60 years old and suffer from arthritis,” said Kenneth Vitale, MD, a sports medicine physician and professor of orthopedic surgery at the University of California, San Diego.
“If you will have arthritis in your knee and you then make it worse with a twist or trauma, the arthritis can flare up. Unfortunately, picklers are notorious for continuing to play despite injuries, which [helps] Her arthritis is getting worse and can eventually require joint alternative surgery.”
Many older people even have low bone density or osteoporosisso that they usually tend to fracture or experience worsening joint wear once they fall than younger people or individuals with higher bone density, he said, adding that he has seen many wrist fractures.
“There was a study A recent study found that pickleball players with wrist fractures required surgery more often than the general population with the same wrist fractures if they were over 65 years old,” he said. That means it's a more aggressive type of fall.
A balancing act
Although the saying “It's all fun and games until someone gets hurt” applies to pickleball, the sport offers many health advantages. Vitale said the game offers players cardiovascular fitness, improved muscle strength and the chance to work on balance and coordination. Like other moderate activities, it may also help release feel-good hormones like endorphins, which fight depression and other mood disorders.
It's no wonder the campaign caught on like wildfire throughout the pandemic.
Brenda Shaeffer, a physical therapist in private practice in Annapolis, MD, points out that the three Rs are vital: “You should be READY for it and know what you're getting into, know your RECOVERY STRATEGY and REST between games,” she said.
She explained that patients often don't understand that pickleball is different than the rest they've done their entire lives. “They're not used to doing the movement pattern that's required of them with their legs – from standing to moving forward and backward to stepping sideways.”
The Star Lunge – an exercise that involves barely bending on the hips while ensuring the core stays still – trains and mimics the lateral movement required to play pickleball. When pickleball players come to her practice, that is what Shaeffer focuses on.
Working on balance is equally vital.
“Pickleball is great for improving balance, but you have to have a certain level [first] to be safe,” said Stephanie Bloom, a physical therapist in Bethesda, MD.
“There are three important sensory systems that help us maintain balance: vision, our muscle and joint receptors and our vestibular system,” she said, pointing out that the latter is responsible for keeping people safe during very fast movements and changes of direction.
“Balance is a problem especially in the aging population, as most people’s eyes have changed significantly,” said Shaeffer. “The [inability] to evaluate what they see. But then the steps they should take are delayed and other people literally fall over.”
To counteract this, Shaeffer recommends an exercise called the Fukuda Step, which may test for balance problems and the body's ability to regulate accordingly. She said she first asks patients to march in place at a speed of about one second for a couple of minute without their feet.
Then she asks them to attempt to do the identical with their arms outstretched at shoulder height, thumbs together, and eyes closed.
The goal is to coach the brain to acknowledge where you're moving – forward or sideways – without using the eyes, in order that this will be completed while the player keeps his eyes on the ball.
In addition, warming up before the sport is vital but rarely happens.
“Pickleball players are notorious for not warming up. They just go out and play,” Vitale said.
And in older adults and lack of muscle mass, strength training, resembling body weight squats, may also help [the] Quadriceps to face up to the stresses of stop-and-go movement, bending, and lunging,” he said.
Other things to consider include recovery after practice, including stretching and fluid intake/rehydration (which is also important during play and to reduce the risk of injury), limiting hours and number of games played, and incorporating other activities, especially those focused on core and leg strengthening and mobility on non-pickleball days.
Dines, Vitale, Shaeffer and Bloom all said the right shoes are also crucial to preventing injuries – especially those involving ankle and stability injuries.
“I've asked a whole lot of patients what they wear once they play, they usually say they simply take what's of their closet,” Vitale said. “While running and walking shoes are made for forward motion, pumps are made for lateral movement, which occurs in a short time in pickleball,” Bloom said.
In conclusion, Vitale gave the following advice:
“I tell every pickleball player who is available in the sport the identical three things,” he said. “Listen to your body. Let pain be your guide. And if it hurts, don't do it. You'll have loads more fun playing pickleball if you happen to follow these three rules. And you'll have the option to play for a few years to come back.”
Correction: Stephanie Bloom's qualifications were incorrectly listed in an earlier version of this story. Bloom is a physical therapist, not a health care provider of physical therapy.