What doctors wish patients knew about preventing pickleball injuries

A racquet sport has been gaining momentum across the U.S., captivating players of all ages and skill levels: pickleball. This is an engaging and accessible sport that is a unique blend of tennis, badminton and ping pong. But as pickleball becomes more mainstream, there is potential for injuries to occur if players are not careful. Whether pickleball is played indoors or outdoors, a sports medicine physician sets out to help patients prevent injuries and enjoy the benefits of this activity.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Christopher Wu, MD, a sports and internal medicine physician at Atlantic Health System, took time to discuss what patients need to know about pickleball health. Atlantic Health System is a member of the AMA Health System Program.

“If you have medical conditions that involve the heart or the lungs and you haven’t really been active leading up to this venture into pickleball, it would be a good idea to see your primary doctor to make sure that everything is optimized for you to pick up some new physical activity,” he said. “It’s really dependent patient to patient on what medical conditions they have and the level of activity prior to getting into the sport.”

Even if you’re medically all clear, Dr. Wu said it is important to get “some lessons or some pointers from either a coach or a friend or colleague who has played and knows proper technique.”

Pickleball is for all ages, but “based on the patients I saw last year when I was in training, a lot of them were middle aged—30s to 50s,” Dr. Wu said, noting that most of the pickleball injuries seen “were all either strains or overuse injuries.”

“You can also have more traumatic, significant injuries like a fracture … but I have not seen that as a result of pickleball. I’m sure it could happen if you were to step wrong, have a very severe injury of some sort,” he said. “You’d be more inclined to think the older populations—especially those individuals who haven’t been that active prior to picking up pickleball and all of a sudden ramping up their activity level from minimal to trying to play several hours a day, multiple times a week—experienced more injuries.

“Their bodies aren’t accustomed to that workload and that can put them at an increased risk of injury while playing pickleball,” he added.

Strain or overuse injuries are likely to be the most common among pickleball players, Dr. Wu said, noting that “overuse injuries would be shoulder pain or knee pain that develops over time—there’s not really one specific moment or movement where you can say, ‘Ow, that really hurt.’

“And either you have to stop playing or take a break. That would be more consistent with overuse injury—something that develops over time in that early specific mechanism or a moment that you can recall,” he added. For example, “pickleball elbow”—which is essentially the same as tennis elbow—is an overuse injury that is “inflammation or irritation of one of the large tendons on the outside of the elbow.”

Pickleball elbow is “more of an overuse injury, which should get better with rest, some physical therapy and a brace that you put over the elbow,” Dr. Wu said. “But that certainly exists in tennis and given that we’re talking about pickleball, if it happens as a result of playing pickleball, then it would be called pickleball elbow.”

“If the inside of your elbow hurts, that’s traditionally called golfer’s elbow. So, every sport has their problem,” he said.

Sprained ankles and pulled hamstrings are examples of acute injuries in pickleball in which “there’s one specific moment where you step wrong or you’re lunging for a ball and you feel some pain or pull in your hamstring and then have to stop playing because of that,” Dr. Wu said. “If you do sustain an ankle sprain and there’s a lot of pain, swelling and you can’t put any weight on it, that’s a situation that I would definitely see a doctor as soon as possible.”

“Generally, in those cases an X-ray is warranted to start to rule out any injury to the bone or any major osseous or bony abnormality,” he said. “But if it’s relatively mild and there isn’t much or any bruising, if you have some pain along the outside of the ankle, but you can bear weight, you can move it without any real pain, that’s something you can try to ice and rest for a couple of days to see if it improves.”

“But the bigger sign would be an inability to bear weight or just a lot of pain and swelling and being unable to really move the ankle at all,” Dr. Wu emphasized.

“From an aerobic or cardiovascular standpoint, playing pickleball certainly can help with those systems,” Dr. Wu said. Playing pickleball can also help with “using your muscles. It will help keep everything functioning and certainly help prevent things like stiffness from inactivity.”

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For example, in the older population, “if they are dealing with some preexisting arthritis or joint pain, in those situations one of the most important factors to consider is to let their body guide how much and how often they’re playing,” he said. “If everything feels good, then they can certainly continue. But if they all of a sudden have a flare up of some knee pain or some shoulder pain, they shouldn’t try to push through it and they need to make sure they have adequate rest before they try to continue.”

“In the older population, it’s a fine balance between doing enough where they feel satisfied and also being cautious of the overuse component,” Dr. Wu said.

To prevent injuries while being active, it is important in the long term to stay active, Dr. Wu said, “whether that’s with some form of resistance training and some aerobic exercise.”

Doing so will help “keep your body in tune with physical activity.

Before playing pickleball, “doing an adequate warmup with dynamic stretching is important,” Dr. Wu said. That means “not the traditional static stretching where you stand there and hold a stretch for 30 seconds or a minute, but doing things like walking lunges, high knees or arm circles.

“It’s more dynamic movements where you’re moving and not just standing in one spot and stretching one specific muscle, making sure that you’re adequately warmed up,” he said. “It’s always a good idea to have a few drops of sweat on your forehead before you actually get into that first match, so you know that your body is warm and ready to go.”

“Cooling down is the best time to do the more static stretches to help with some flexibility and keep the muscles loose and ready to go,” Dr. Wu said. “In terms of cooling down after you push yourself for a little while, you want to give your body adequate time to recover and go back to baseline before you pack up and go home.”

“There’s no particular thing you need to do but consider throwing in some stretches at the end as the activity winds down,” he said.

“A general piece of advice we always tell all patients is hydration is very important,” Dr. Wu said. “You want to make sure that you’re actively hydrated, not just during the activity or the match, but also before and after.”

“Let’s say you’re coming from work or something. You want to make sure that during the day you are maintaining adequate water or fluid intake and not trying to cram it all in right before the match,” he said.

“Given the similarities between pickleball and tennis, something like a tennis shoe would be a good idea to have, aside from proper technique and equipment, warming up and hydrating,” Dr. Wu said. “Footwear wise, there are shoes specifically designed for tennis.

“Just a few ways that they are different from a running shoe is tennis shoes have much firmer outsoles because you’re doing much more cutting or pivoting to stutter step movements as opposed to running where the sole may be softer and provide more cushioning, which is good for running,” he added. “But in a sport like pickleball or tennis where you’re making sudden movements, you want a grip, so you want a shoe that’s a little firmer on the sides so that you have more support of the foot when you are making those movements.”

“It helps to reduce the risk of potentially rolling your ankle whereas a running shoe likely will have more cushioning, but not as much support, especially when you’re making lateral movements,” Dr. Wu said. “Most importantly, a shoe should be comfortable. If it’s not comfortable, you don’t want to wear it.”

“A general principle that we always tell patients we see is: If something hurts or if something bothers you, of course don’t do it. That’s your body’s way of telling you that it doesn’t like that movement or that position. So, it’s something you want to avoid,” Dr. Wu said. “In terms of injury management, a lot of the overuse injuries can be managed conservatively. In other words, not everything requires surgery, but it some of those more significant injuries like a fracture or something gets dislocated that potentially may need surgery.”

“If you have some mild elbow pain or you have some mild knee pain, those are things that should generally improve with some rest, ice and a short course of Tylenol or Motrin if you need that for pain control,” he said. “But if you have an injury that is nagging you and it’s not getting better with conservative management, that may be a good sign to go for a medical evaluation with your doctor to make sure that there’s nothing more significant going on that is being missed.”

There are many benefits to pickleball and other sporting activities “where you can get your heart rate up and be more active,” Dr. Wu said. “But patients or athletes should know their limits especially if it’s been some time since they’ve really been active and something hurts or if something doesn’t feel right, then the last thing they should do is try to push through it.”

“Many of the more minor or mild injuries can get better with just conservative management, but if things are not progressing as expected, patients or athletes shouldn’t hesitate to seek medical attention,” he said. “Pickleball is great. I’m glad that it’s picked up so much. Hopefully more people get into it and don’t have to deal with the potential injuries.”