Abstract
Purpose
To report the estimated number and the types of pickleball-related injuries stratified by sex and age presenting to U.S. emergency departments from 2020 to 2022, as estimated by the National Electronic Injury Surveillance System (NEISS) database.
Methods
Data from the NEISS database were queried to characterize pickleball-related injuries that presented to 96 NEISS-affiliated emergency departments across the United States between 2020 and 2022. The estimated numbers of injuries and hospital admissions were calculated using weights assigned by the NEISS based on geographical location. Narratives for each emergency department visit were manually reviewed to categorize injuries by type and site. Multivariable analyses were used to determine risk factors associated with pickleball-related hospital admissions.
Results
The estimated number of annual pickleball-related injuries presenting to U.S. emergency departments increased by 91% from 2020 to 2022 (8,894 injuries vs 16,997 injuries). Pickleball-related hospital admissions increased by 257% from 2020 in 2022 (992 hospital admissions vs 3,541 hospital admissions). Most injuries (73%, 9,932 estimated injuries per year) were sustained by patients aged between 60 and 79 years (mean ± standard deviation, 63.9 ± 14.7 years). The most common types of injuries were fractures (29%, 3,990 estimated injuries per year) and strains/sprains (21%, 2,808 estimated injuries per year). Multivariable analyses controlling for age, sex, injury type, and injury site showed that patients aged 65 years or older were at an increased risk of hospitalization (odds ratio, 2.48; 95% confidence interval, 1.54-4.11; P < .001) compared with those younger than 65 years.
Conclusions
The estimated number of pickleball-related injuries presenting to U.S. emergency departments and subsequent hospital admissions has increased by 91% and 257%, respectively, from 2020 to 2022. Patients who were aged 65 years or older at the time of injury were at an increased risk of hospital admission.
Clinical Relevance
Understanding the current trends and types of pickleball-related injuries presenting to U.S. emergency departments is critical toward the development of injury prevention measures and understanding the U.S. health care system, particularly as participation in pickleball continues to grow.
Pickleball, one of the fastest growing sports in the United States, combines various elements of tennis, badminton, and ping-pong and can be played both indoors and outdoors. Pickleball uses a perforated plastic ball that reduces the maximum projectile velocity and overall intensity of the sport, making it an accessible recreational activity for individuals of all ages and athletic capabilities.1 According to the Association of Pickleball Players 2023 Participation Report, 48.3 million individuals—nearly one-fifth of the U.S. adult population—had played pickleball within the past year, a 35% increase from August 2022.2
Pickleball has become a popular sport for individuals older than 65 years, given its low impact compared with tennis. However, as pickleball continues to become increasingly popular, pickleball-related injuries, emergency department visits, and hospital admissions, especially for the geriatric community, have become a growing concern for the orthopaedic community.1,3,4 Older individuals have lower functional capacities and poorer bone quality than their younger counterparts; therefore, these patients may be at a greater risk of sustaining injuries on the pickleball court.1,5 Furthermore, older patients may require additional monitoring after sustaining injuries, have longer recovery periods, and as a result, be admitted to hospitals more frequently than younger patients.
Although prior studies have reported on pickleball-related injuries, these studies have assumed that pickleball-related injuries are identical to injuries from other racket sports such as tennis, squash, and badminton or have been limited to specific injury types (e.g., fractures or upper-extremity injuries) and/or single-institution data.6, 7, 8, 9 The studies that have reported national weighted estimates of all pickleball-related injuries presenting to U.S. emergency departments, as estimated by the National Electronic Injury Surveillance System (NEISS) database, have used 2001-2019 data and may substantially underestimate the frequency of pickleball-related injuries given the recent rapid growth of the sport.1,10,11 Moreover, a better understanding of the risk factors associated with hospital admission after pickleball participation may help with injury prevention in at-risk populations.
The purpose of this study was to report the estimated number and the types of pickleball-related injuries stratified by sex and age presenting to U.S. emergency departments and from 2020 to 2022, as estimated by the NEISS database. In addition, this study sought to determine the following: (1) types and sites of pickleball-related injuries presenting to NEISS-affiliated emergency departments stratified by sex and age group, (2) incidence of hospital admissions associated with pickleball injuries, and (3) risk factors for hospital admission after sustaining a pickleball-related injury. We hypothesized that the annual estimated number of pickleball-related injuries would increase from 2020 to 2022.
Methods
Data Source
The U.S. Consumer Product Safety Commission operates the NEISS database, which is a public health research tool that is accessible through the NEISS Estimates Query Builder.12 The NEISS collects injury data from emergency departments of 96 participating hospitals that have been selected by the U.S. Consumer Product Safety Commission as a probability sample of all U.S. hospitals with a 24-hour emergency department and at least 6 beds. The samples of academic and community hospitals are selected based on their representation of all other hospitals of their size and unique characteristics, thereby allowing for the calculation of national estimates from statistical weights assigned to each hospital. For each emergency department visit, information such as the date of injury, patient demographic characteristics, discharge disposition, site of injury, activities and products associated with the injury, narrative, and suspected injury diagnosis were logged. No institutional review board approval was required for this study because the NEISS database contains only deidentified patient data.
Patient Selection and Data Collection
All patient encounters at the 96 participating NEISS emergency departments between January 1, 2020, and December 31, 2022, that were associated with “sports and recreation equipment” were first identified. Pickleball-related injuries were then identified manually by reviewing the narrative associated with each patient encounter. Patient encounters with incomplete narratives were excluded. Injuries were then categorized by patient demographic characteristics, discharge disposition, hospital size/type (small, medium, large, very large, children’s), injury type (e.g., concussion, fracture, or dislocation), injury site (e.g., head/face, upper extremity, trunk, or lower extremity), and orthopaedic injury (e.g., strain/sprain, fracture, dislocation, or tear) versus non-orthopaedic injury (e.g., concussion, cardiac arrest, or pneumothorax).
Statistical Analyses
Continuous variables were presented as means and standard deviations, and categorical variables were presented as counts and percentages. The estimated number of injuries was calculated using weights assigned by the NEISS database based on the geographical location of the injury. Univariable analyses were performed comparing patient and injury characteristics between patients who were admitted and those who were treated and discharged from the emergency department. Multivariable logistic regressions for predictors of hospital admission were performed controlling for patient age, sex, injury type, and injury site. All statistical analyses were performed using the R package (version 3.6.1; The R Foundation, Vienna, Austria). Findings were considered statistically significant if P < .05.
Results
From January 1, 2020 to December 31, 2022, there were 710 incidents of pickleball-related injuries presenting to NEISS-affiliated emergency departments, representing a national weighted estimate of 40,698 injuries. The number of actual and estimated injuries increased substantially from 2020 (n = 143, 8,894 estimated injuries) to 2021 (n = 279, 14,808 estimated injuries, 67% increase vs 2020) and 2022 (n = 288, 16,997 estimated injuries, 91% increase vs 2020) (Fig 1A). Further analyses showed that women aged between 60 and 69 years contributed largely to this finding, with the number of estimated injuries increasing from 1,540 in 2020 to 3,858 in 2022 (+151%) (Fig 1B). Injuries were slightly more common in women (51%, 6,918 estimated injuries per year) and occurred most commonly in individuals aged between 60 and 79 years (73%, 9,932 estimated injuries per year) (Table 1). The mean age was 63.9 years (standard deviation, 14.7 years).
Fig 1.
(A) Estimated number of pickleball-related injuries presenting to U.S. emergency departments stratified by year and age group. (B) Estimated number of pickleball injuries presenting to U.S. emergency departments stratified by year, age group, and sex.
Table 1.
Actual and Estimated Numbers of Annual Pickleball-Related Injuries Presenting to U.S. Emergency Departments (NEISS Database, 2020-2022) Stratified by Patient Demographic Characteristics, Site of Injury, and Discharge Disposition
| Variable | Actual |
Estimate |
||
|---|---|---|---|---|
| n | % | n | % | |
| Total | 237 | — | 13,566 | — |
| Sex | ||||
| Male | 115 | 48 | 6,648 | 49 |
| Female | 122 | 52 | 6,918 | 51 |
| Age | ||||
| <50 yr | 24 | 10 | 1,061 | 8 |
| 50-59 yr | 33 | 14 | 1,846 | 14 |
| 60-69 yr | 88 | 41 | 5,274 | 39 |
| 70-79 yr | 76 | 36 | 4,658 | 34 |
| ≥80 yr | 15 | 8 | 728 | 5 |
| Site of injury | ||||
| Head/neck | 30 | 13 | 1,656 | 12 |
| Upper extremity | 77 | 33 | 4,223 | 31 |
| Trunk | 54 | 23 | 3,453 | 25 |
| Lower extremity | 63 | 27 | 3,535 | 26 |
| Systemic/multiple parts of body | 12 | 5 | 698 | 5 |
| Orthopaedic injury vs non-orthopaedic injury | ||||
| Orthopaedic | 131 | 55 | 7,504 | 55 |
| Non-orthopaedic | 106 | 45 | 6,062 | 45 |
| Discharge disposition | ||||
| Treated/examined and discharged | 196 | 83 | 10,909 | 80 |
| Treated and admitted/hospitalized | 35 | 15 | 2,308 | 17 |
| Treated and transferred | 3.7 | 2 | 267 | 2 |
| Death | 1.3 | 1 | 82 | 1 |
| Hospital size/type | ||||
| Small | 55 | 23 | 4,188 | 31 |
| Medium | 99 | 42 | 7,417 | 55 |
| Large | 14 | 6 | 814 | 6 |
| Very large | 65 | 27 | 1,122 | 8 |
| Children's | 4 | 2 | 25 | 0.2 |
NEISS, National Electronic Injury Surveillance System.
Injuries to the upper extremity were most common (31%), followed by those to the lower extremity (26%), trunk (25%), and head/neck (12%). Patients who presented to the emergency department with systemic injuries (e.g., cardiac events) or injuries to multiple parts of the body accounted for 5% of all injuries (698 estimated injuries per year). Most injuries (55%) were orthopaedic injuries, which included strains/sprains; fractures; dislocations; and muscle, tendon, ligament, and cartilage tears. Most patients (80%) were treated/examined and discharged from the emergency department. However, 17% of patients were treated and admitted (2,308 estimated injuries per year) and 2% of patients were treated and transferred (267 estimated injuries per year). The estimated number of hospital admissions increased from 992 in 2020 to 2,392 in 2021 (141% increase vs 2020) to 3,541 in 2022 (257% increase vs 2020). Most injuries presented to small- or medium-sized hospitals (86%, 11,605 estimated injuries per year).
Fractures and strains/sprains represented half of all injuries and an estimated 6,798 injuries per year (Table 2). Other injuries and diagnoses such as chest pain and closed head injuries accounted for a quarter of the injuries. Patients who presented with lacerations (739 estimated injuries per year), abrasions and contusions (632 estimated injuries per year), or syncope, heat exhaustion, and dizziness (502 estimated injuries per year) accounted for approximately 15% of all emergency department visits. Whereas strains/sprains accounted for the greatest proportion of injuries in men (25%, 1,704 estimated injuries per year), fractures accounted for the greatest proportion of injuries in women (40%, 2,762 estimated injuries per year) (Table 3). Fractures represented a greater proportion of injuries (32%, 2,747 estimated injuries per year) than strains/sprains (19%, 1,617 estimated injuries per year) in patients aged 65 years or older (Table 4). However, these 2 injury types represented a more comparable proportion of injuries (strains/sprains, 23% [1,191 estimated injuries per year]; fractures, 24% [1,243 estimated injuries per year]) in patients younger than 65 years.
Table 2.
Actual and Estimated Numbers of Annual Pickleball-Related Injuries Presenting to U.S. Emergency Departments (NEISS Database, 2020-2022) Stratified by Injury Type
| Actual |
Estimate |
|||
|---|---|---|---|---|
| n | % of Total | n | % of Total | |
| Variable | ||||
| Fracture | 71 | 30 | 3,990 | 29 |
| Other injury/unspecified injury and pain | 58 | 24 | 3,472 | 25 |
| Strain/sprain | 47 | 20 | 2,808 | 21 |
| Laceration | 14 | 6 | 739 | 5 |
| Abrasion and contusion | 12 | 5 | 632 | 5 |
| Syncope, heat exhaustion, and dizziness | 9.0 | 4 | 502 | 4 |
| Muscle, ligament, tendon, and cartilage tear | 8.3 | 3 | 469 | 3 |
| Dislocation | 6.0 | 3 | 342 | 3 |
| Cardiac arrest and myocardial infarction | 3.3 | 1 | 233 | 2 |
| Hematoma | 3.7 | 2 | 192 | 1 |
| Concussion and traumatic brain injury | 2.7 | 1 | 139 | 1 |
| Death | 1.3 | 1 | 82 | 1 |
| Pneumothorax | 1.0 | 0 | 74 | 1 |
| Total | 238 | — | 13,675 | — |
NOTE. Patients who sustained a fracture and had a pneumothorax were counted under both categories. Patients who had a cardiac arrest and then died were counted under both categories.
NEISS, National Electronic Injury Surveillance System.
Table 3.
Estimated Number of Annual Pickleball-Related Injuries Presenting to U.S. Emergency Departments (NEISS Database, 2020-2022) Stratified by Injury Type and Sex
| Male Individuals |
Female Individuals |
|||
|---|---|---|---|---|
| Estimate, n | % of Total | Estimate, n | % of Total | |
| Variable | ||||
| Abrasion and contusion | 307 | 5 | 326 | 5 |
| Laceration | 391 | 6 | 348 | 5 |
| Strain/sprain | 1,704 | 25 | 1,103 | 16 |
| Fracture | 1,229 | 18 | 2,762 | 40 |
| Hematoma | 127 | 2 | 65 | 1 |
| Dislocation | 234 | 3 | 108 | 2 |
| Tear | 384 | 6 | 85 | 1 |
| Cardiac arrest and myocardial infarction | 185 | 3 | 48 | 1 |
| Syncope, heat exhaustion, and dizziness | 255 | 4 | 247 | 4 |
| Pneumothorax | 51 | 1 | 23 | 0 |
| Concussion and traumatic brain injury | 82 | 1 | 57 | 1 |
| Other injury | 1,727 | 26 | 1,746 | 25 |
| Death | 61 | 1 | 22 | 0.3 |
| Total | 6,735 | — | 6,939 | — |
NOTE. Patients who sustained a fracture and had a pneumothorax were counted under both categories. Patients who had a cardiac arrest and then died were counted under both categories.
NEISS, National Electronic Injury Surveillance System.
Table 4.
Estimated Number of Annual Pickleball-Related Injuries Presenting to U.S. Emergency Departments (NEISS Database, 2020-2022) Stratified by Injury Type and Age Group
| Age < 65 yr |
Age ≥ 65 yr |
|||
|---|---|---|---|---|
| Estimate, n | % of Total | Estimate, n | % of Total | |
| Variable | ||||
| Abrasion and contusion | 379 | 7 | 253 | 3 |
| Laceration | 302 | 6 | 438 | 5 |
| Strain/sprain | 1,191 | 23 | 1,617 | 19 |
| Fracture | 1,243 | 24 | 2,747 | 32 |
| Hematoma | 86 | 2 | 106 | 1 |
| Dislocation | 110 | 2 | 232 | 3 |
| Tear | 289 | 6 | 180 | 2 |
| Cardiac arrest and myocardial infarction | — | 0 | 233 | 3 |
| Syncope, heat exhaustion, and dizziness | 147 | 3 | 354 | 4 |
| Pneumothorax | 25 | 0 | 49 | 1 |
| Concussion and traumatic brain injury | 8 | 0 | 131 | 2 |
| Other injury | 1,382 | 27 | 2,090 | 25 |
| Death | — | 0 | 82 | 1 |
| Total | 5,163 | — | 8,511 | — |
NOTE. Patients who sustained a fracture and had a pneumothorax were counted under both categories. Patients who had a cardiac arrest and then died were counted under both categories.
NEISS, National Electronic Injury Surveillance System.
Further subcategorization of pickleball-related injuries showed that fractures were most commonly injuries to the upper extremity (63%, 2,546 estimated injuries per year) or trunk (21%, 858 estimated injuries per year) (Tables 5 and 6). In contrast, most strains/sprains (62%, 1,734 estimated injuries per year) were injuries to the lower extremity. Patients aged 65 years or older sustained a greater proportion of strains/sprains to the upper extremity (34%, 551 estimated injuries per year) compared with patients younger than 65 years (11%, 126 estimated injuries per year) (Table 7). Regarding “other injuries,” patients younger than 65 years were more likely to sustain muscle, ligament, tendon, and cartilage tears (38%, 384 estimated injuries per year) whereas patients aged 65 years or older were more likely to present for syncope, heat exhaustion, and dizziness (51%, 247 estimated injuries per year).
Table 5.
Actual and Estimated Numbers of Annual Pickleball-Related Injuries Presenting to U.S. Emergency Departments (NEISS Database, 2020-2022) Stratified by Injury Type and Site of Injury
| Actual |
Estimate |
|||
|---|---|---|---|---|
| n | % | n | % | |
| Variable | ||||
| Abrasion and contusion | ||||
| Head/face | 1.0 | 8 | 77 | 12 |
| Upper extremity | 6.7 | 56 | 344 | 54 |
| Trunk | 2.0 | 17 | 93 | 15 |
| Lower extremity | 2.3 | 19 | 119 | 19 |
| Laceration | ||||
| Head/face | 10 | 74 | 579 | 78 |
| Upper extremity | 2.7 | 19 | 92 | 12 |
| Lower extremity | 1.0 | 7 | 69 | 9 |
| Strain/sprain | ||||
| Upper extremity | 11 | 23 | 677 | 24 |
| Trunk | 6.7 | 14 | 397 | 14 |
| Lower extremity | 30 | 63 | 1,734 | 62 |
| Fracture | ||||
| Head/face | 3.0 | 4 | 111 | 3 |
| Upper extremity | 47 | 65 | 2,546 | 63 |
| Trunk | 14 | 19 | 858 | 21 |
| Lower extremity | 8.3 | 12 | 519 | 13 |
| Hematoma | ||||
| Head/face | 2.3 | 64 | 131 | 69 |
| Lower extremity | 1.3 | 36 | 60 | 31 |
| Dislocation | ||||
| Upper extremity | 5.7 | 94 | 336 | 98 |
| Lower extremity | 0.3 | 6 | 6.4 | 2 |
| Other injury | ||||
| Muscle, ligament, tendon, and cartilage tear | 8.3 | 32 | 469 | 31 |
| Syncope, heat exhaustion, and dizziness | 9.0 | 35 | 502 | 33 |
| Pneumothorax | 1.0 | 4 | 74 | 5 |
| Cardiac arrest, myocardial infarction | 3.3 | 13 | 233 | 16 |
| Concussion, traumatic brain injury | 2.7 | 10 | 139 | 9 |
| Death | 1.3 | 5 | 82 | 6 |
| Unspecified injury and pain | ||||
| Head/face | 11 | 18 | 619 | 18 |
| Upper extremity | 4.7 | 8 | 272 | 8 |
| Trunk | 30 | 52 | 1,992 | 57 |
| Lower extremity | 12 | 21 | 584 | 17 |
| Other: systemic/entire body | 0.3 | 1 | 5.1 | 0 |
| Total | 239 | — | 13,718 | — |
NOTE. Patients who sustained a fracture and had a pneumothorax were counted under both categories. Patients who had a cardiac arrest and then died were counted under both categories. Patients who sustained multiple injuries (e.g., ≥2 fractures) to multiple body parts (e.g., upper extremity and lower extremity) were counted under both categories.
NEISS, National Electronic Injury Surveillance System.
Table 6.
Estimated Number of Annual Pickleball-Related Injuries Presenting to U.S. Emergency Departments (NEISS Database, 2020-2022) Stratified by Sex, Injury Type, and Site of Injury
| Male Individuals |
Female Individuals |
|||
|---|---|---|---|---|
| Estimate, n | % of Total | Estimate, n | % of Total | |
| Variable | ||||
| Abrasion and contusion | ||||
| Head/face | 26 | 9 | 51 | 16 |
| Upper extremity | 150 | 49 | 194 | 60 |
| Trunk | 69 | 22 | 25 | 8 |
| Lower extremity | 62 | 20 | 57 | 17 |
| Laceration | ||||
| Head/face | 327 | 84 | 251 | 72 |
| Upper extremity | 64 | 16 | 28 | 8 |
| Lower extremity | — | 0 | 69 | 20 |
| Strain/sprain | ||||
| Upper extremity | 406 | 24 | 271 | 25 |
| Trunk | 223 | 13 | 174 | 16 |
| Lower extremity | 1,075 | 63 | 659 | 60 |
| Fracture | ||||
| Head/face | 38 | 3 | 73 | 3 |
| Upper extremity | 546 | 44 | 2,000 | 71 |
| Trunk | 451 | 37 | 407 | 15 |
| Lower extremity | 200 | 16 | 319 | 11 |
| Hematoma | ||||
| Head/face | 93 | 74 | 38 | 58 |
| Lower extremity | 33 | 26 | 27 | 42 |
| Dislocation | ||||
| Upper extremity | 228 | 97 | 108 | 100 |
| Lower extremity | 6.4 | 3 | — | 0 |
| Other injury | ||||
| Muscle, ligament, tendon, and cartilage tear | 384 | 38 | 85 | 18 |
| Syncope, heat exhaustion, and dizziness | 255 | 25 | 247 | 51 |
| Pneumothorax | 51 | 5 | 23 | 5 |
| Cardiac arrest, myocardial infarction | 185 | 18 | 48 | 10 |
| Concussion, traumatic brain injury | 82 | 8 | 57 | 12 |
| Death | 61 | 6 | 22 | 4 |
| Unspecified injury and pain | ||||
| Head/face | 206 | 12 | 413 | 24 |
| Upper extremity | 135 | 8 | 138 | 8 |
| Trunk | 1,082 | 63 | 909 | 52 |
| Lower extremity | 299 | 17 | 285 | 16 |
| Other: systemic/entire body | 5.1 | 0.3 | — | 0 |
| Total | 6,741 | — | 6,977 | — |
NOTE. Patients who sustained a fracture and had a pneumothorax were counted under both categories. Patients who had a cardiac arrest and then died were counted under both categories. Patients who sustained multiple injuries (e.g., ≥2 fractures) to multiple body parts (e.g., upper extremity and lower extremity) were counted under both categories.
NEISS, National Electronic Injury Surveillance System.
Table 7.
Estimated Number of Annual Pickleball-Related Injuries Presenting to U.S. Emergency Departments (NEISS Database, 2020-2022) Stratified by Sex, Injury Type, and Site of Injury
| Age < 65 yr |
Age ≥ 65 yr |
|||
|---|---|---|---|---|
| Estimate, n | % of Total | Estimate, n | % of Total | |
| Variable | ||||
| Abrasion and contusion | ||||
| Head/face | 51 | 13 | 26 | 10 |
| Upper extremity | 197 | 52 | 146 | 58 |
| Trunk | 50 | 13 | 44 | 17 |
| Lower extremity | 81 | 21 | 37 | 15 |
| Laceration | ||||
| Head/face | 251 | 83 | 327 | 75 |
| Upper extremity | 28 | 9 | 64 | 15 |
| Lower extremity | 23 | 8 | 46 | 10 |
| Strain/sprain | ||||
| Upper extremity | 126 | 11 | 551 | 34 |
| Trunk | 189 | 16 | 208 | 13 |
| Lower extremity | 876 | 74 | 857 | 53 |
| Fracture | ||||
| Head/face | 47 | 4 | 64 | 2 |
| Upper extremity | 863 | 69 | 1,683 | 60 |
| Trunk | 138 | 11 | 720 | 26 |
| Lower extremity | 200 | 16 | 319 | 11 |
| Hematoma | ||||
| Head/face | 54 | 63 | 78 | 73 |
| Lower extremity | 32 | 37 | 28 | 27 |
| Dislocation | ||||
| Upper extremity | 104 | 94 | 232 | 100 |
| Lower extremity | 6.4 | 6 | — | 0 |
| Other injury | ||||
| Muscle, ligament, tendon, and cartilage tear | 289 | 62 | 180 | 17 |
| Syncope, heat exhaustion, and dizziness | 147 | 31 | 354 | 34 |
| Pneumothorax | 25 | 5 | 49 | 5 |
| Cardiac arrest, myocardial infarction | — | 0 | 233 | 23 |
| Concussion, traumatic brain injury | 8 | 2 | 131 | 13 |
| Death | — | 0 | 82 | 8 |
| Unspecified injury and pain | ||||
| Head/face | 165 | 12 | 454 | 22 |
| Upper extremity | 100 | 7 | 173 | 8 |
| Trunk | 775 | 56 | 1,217 | 58 |
| Lower extremity | 337 | 24 | 247 | 12 |
| Other: systemic/entire body | 5.1 | 0.4 | — | 0 |
| Total | 5,169 | — | 8,549 | — |
NOTE. Patients who sustained a fracture and had a pneumothorax were counted under both categories. Patients who had a cardiac arrest and then died were counted under both categories. Patients who sustained multiple injuries (e.g., ≥2 fractures) to multiple body parts (e.g., upper extremity and lower extremity) were counted under both categories.
NEISS, National Electronic Injury Surveillance System.
The average age of patients who were admitted after sustaining a pickleball-related injury was significantly higher than that of patients who were treated and discharged from the emergency department (69.5 ± 7.5 years vs 62.7 ± 15.6 years, P < .001). There was no statistically significant difference in rates of hospital admission by sex (Table 8). Hospital admission rates were significantly higher for patients who sustained non-orthopaedic injuries compared with orthopaedic injuries (P < .001). Rates of hospital admission also differed significantly by site of injury (P < .001) and hospital size/type (P = .013). When controlling for age, sex, injury type, and injury site, multivariable analyses showed that patients aged 65 years or older were at an increased risk of hospitalization (odds ratio, 2.48; 95% confidence interval, 1.54-4.11; P < .001) compared with those younger than 65 years (Table 9).
Table 8.
Demographic Characteristics and Injury Types of Patients Admitted Versus Examined and Released After Presentation to NEISS Emergency Departments for Pickleball-Related Injuries
| Variable | Admitted |
Examined and Released |
P Value | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Age group | <.001∗ | ||||
| <50 yr | 1 | 1 | 70 | 12 | |
| 50-59 yr | 9 | 8 | 90 | 15 | |
| 60-69 yr | 40 | 36 | 222 | 38 | |
| 70-79 yr | 50 | 46 | 172 | 29 | |
| ≥80 yr | 10 | 9 | 35 | 6 | |
| Sex | .491 | ||||
| Male | 57 | 52 | 281 | 48 | |
| Female | 53 | 48 | 308 | 52 | |
| Injury type | <.001∗ | ||||
| Non-orthopaedic | 75 | 68 | 239 | 41 | |
| Orthopaedic | 35 | 32 | 350 | 59 | |
| Injury location | <.001∗ | ||||
| Face/head | 3 | 3 | 79 | 13 | |
| Upper extremity | 12 | 11 | 217 | 37 | |
| Trunk | 68 | 62 | 84 | 14 | |
| Lower extremity | 7 | 6 | 180 | 31 | |
| Systemic/multiple parts of body | 8 | 7 | 20 | 3 | |
| Other | 12 | 11 | 9 | 2 | |
| Hospital size/type | .013∗ | ||||
| Small | 26 | 24 | 132 | 22 | |
| Medium | 58 | 53 | 237 | 40 | |
| Large | 8 | 7 | 31 | 5 | |
| Very large | 18 | 16 | 177 | 30 | |
| Children's | — | 0 | 12 | 2 | |
NEISS, National Electronic Injury Surveillance System.
Statistically significant.
Table 9.
Risk Factors for Hospital Admission Adjusted for Patient Age, Sex, Injury Type, and Location of Injury
| Comparison | Odds Ratio | 95% CI | P Value |
|---|---|---|---|
| Age: ≥ 65 yr vs < 65 yr | 2.48 | 1.54-4.11 | <.001∗ |
| Sex: male vs female | 1.40 | 0.90-2.16 | .142 |
| Injury type | |||
| Dislocation/fracture vs non-orthopaedic injury | 0.52 | 0.32-0.83 | .007∗ |
| Strain/sprain vs non-orthopaedic injury | 0.04 | 0.01-0.14 | <.001∗ |
| Muscle, ligament, tendon, and cartilage tear vs non-orthopaedic injury | 0.13 | 0.01-0.66 | .052 |
CI, confidence interval.
Statistically significant.
Discussion
The most important findings of this study are as follows: The number of estimated pickleball-related injuries increased by 91% from 2020 (8,894 injuries) to 2022 (16,997 injuries). Fractures were most commonly localized to the upper extremity (63%, 2,546 estimated injuries per year) or trunk (21%, 858 estimated injuries per year), whereas most strains/sprains (62%, 1,734 estimated injuries per year) were localized to the lower extremity. The estimated number of hospital admissions increased from 992 in 2020 to 3,541 in 2022 (257% increase). Finally, patients who were aged 65 years or older were more than 2 times more likely to be admitted to the hospital than patients younger than 65 years. Understanding the current trends and types of pickleball-related injuries presenting to U.S. emergency departments is critical toward the development of injury prevention measures and understanding the U.S. health care system, particularly as participation in pickleball continues to grow.
This study examined contemporary data (2020-2022) regarding the estimated number of pickleball-related injuries presenting to U.S. emergency departments, compared with prior NEISS studies,1,10,11 and found a 91% increase from 2020 to 2022. Fractures, particularly those of the upper extremity, accounted for the greatest proportion of pickleball-related injuries (29%, 3,990 injuries per year). In contrast, prior studies that have examined pickleball-related injuries have identified strains/sprains as the most common type of injury sustained from pickleball.10 Bone quality tends to decrease with age and can therefore place older patients, especially postmenopausal women, at an increased risk of fracture after a fall.13,14 Studies have shown that individuals aged 65 years or older have one of the highest incidence rates of upper-extremity fractures, such distal radius fractures.14 Further studies are needed to ascertain more granular information regarding these pickleball-related fractures to help injury prevention given that our study can only provide information based on population-level data.
This study found that hospital admissions increased by 257% from 2020 in 2022 (992 hospital admissions vs 3,541 hospital admissions). In addition, patients who were aged 65 years or older were 2.4 times more likely to be admitted to the hospital than patients younger than 65 years. Older patients are presumably at a lower level of function at the time of injury, may require additional monitoring after sustaining an injury, and may therefore need to be admitted more frequently than younger patients.15 As pickleball and the associated number of injuries continue to grow, future efforts directed toward injury prevention in this at-risk population may be warranted.
As the popularity of pickleball and rates of pickleball-related injuries continue to increase, especially within the geriatric community, costs to the U.S. health care system become a growing concern. Moore and Liang16 conducted a study in 2020 that examined costs of emergency department visits in the United States and found that costs tend to increase with increasing age. Whereas the average emergency department visit for patients aged 17 years or younger costs $290, each emergency department visit for patients aged 65 years or older costs an average of $690. The societal costs of the aforementioned increase in pickleball-related injuries presenting to U.S. emergency departments are beyond the scope of this study but could be an area of future investigation, given the epidemiologic data reported in this study. Furthermore, researchers should aim to develop pickleball-specific injury prevention programs and equipment. Proper footwear, ankle braces, adequate warm-up exercises, and resistance training programs all may help to reduce the number of falls and, ultimately, limit injuries such as sprains, strains, and fractures, especially in the elderly population.3,17
Limitations
This retrospective study has limitations. Only injuries that presented to NEISS-affiliated emergency departments were included; injuries that did not present to NEISS-affiliated emergency departments were not included in the analyses. As such, the use of the NEISS database creates the possibility of a sampling bias and may even result in an underestimation of pickleball-related injuries presenting to U.S. emergency departments during the study period. Furthermore, the NEISS database assigns weighted estimates to each injury, and therefore, small inaccuracies in these weighted values may result in significant errors in estimated injury rates. Finally, the NEISS database included some general narratives (e.g., upper-extremity fracture instead of distal radius fracture) that limited our ability to provide more granular data regarding pickleball-related injuries. Nevertheless, our team examined all NEISS sports-related injuries from 2020 to 2022 and manually reviewed the narratives to identify pickleball-related cases to ensure that this study provided as comprehensive of an analysis as the data set would allow.
Conclusions
The estimated number of pickleball-related injuries presenting to U.S. emergency departments and subsequent hospital admissions has increased by 91% and 257%, respectively, from 2020 to 2022. Patients who were aged 65 years or older at the time of injury were at an increased risk of hospital admission.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.E.J. is on the Arthroscopy Editorial Board. All other authors (R.C., J.M., B.K., M.S.Y., C.J.O., C.W., J.S.D., B.M.K.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
- 1.Weiss H., Dougherty J., DiMaggio C. Non-fatal senior pickleball and tennis-related injuries treated in United States emergency departments, 2010-2019. Inj Epidemiol. 2021;8:34. doi: 10.1186/s40621-021-00327-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Association of Pickleball Players New APP research reveals nearly 50 million adult Americans have played pickleball in the last 12 months; average age drops to 35. 2024. https://www.theapp.global/news/nearly-50-million-adult-americans-have-played-pickleball
- 3.Greiner N. Pickleball: Injury considerations in an increasingly popular sport. Mo Med. 2019;116:488–491. [PMC free article] [PubMed] [Google Scholar]
- 4.Vitale K., Liu S. Pickleball: Review and clinical recommendations for this fast-growing sport. Curr Sports Med Rep. 2020;19:406–413. doi: 10.1249/JSR.0000000000000759. [DOI] [PubMed] [Google Scholar]
- 5.Aspray T.J., Hill T.R. Osteoporosis and the ageing skeleton. Subcell Biochem. 2019;91:453–476. doi: 10.1007/978-981-13-3681-2_16. [DOI] [PubMed] [Google Scholar]
- 6.Kasper A.A., Gibbons J.L., Abboudi J., et al. Pickleball- and paddleball-related injuries to the upper extremity. Cureus. 2023;15 doi: 10.7759/cureus.39831. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Ghattas Y.S., Zeblisky P., Cassinat J., Aceto M., Spindler K.P., Cannada L.K. Pickleball-related fractures in the United States from 2002 to 2022: An analysis using the NEISS database. Orthop J Sports Med. 2024;12 doi: 10.1177/23259671241255674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Olsen A.A., Li A., Johnson D.D., Manson H.C. Pickleball primer: An overview of common injuries, treatment, and optimization strategies in pickleball athlete. J Am Acad Orthop Surg. 2024;32:763–770. doi: 10.5435/JAAOS-D-23-00705. [DOI] [PubMed] [Google Scholar]
- 9.Azar F.M., Lamplot J.D., Bernholt D.L., Spence D.D. Pickleball: A standard review of injury prevalence and prevention in a rapidly growing sport. J Am Acad Orthop Surg. 2024;32:e1130–e1141. doi: 10.5435/JAAOS-D-24-00151. [DOI] [PubMed] [Google Scholar]
- 10.Forrester M.B. Pickleball-related injuries treated in emergency departments. J Emerg Med. 2020;58:275–279. doi: 10.1016/j.jemermed.2019.09.016. [DOI] [PubMed] [Google Scholar]
- 11.Changstrom B., McBride A., Khodaee M. Epidemiology of racket and paddle sports-related injuries treated in the United States emergency departments, 2007-2016. Phys Sportsmed. 2022;50:197–204. doi: 10.1080/00913847.2021.1892467. [DOI] [PubMed] [Google Scholar]
- 12.U.S. Consumer Product Safety Commission National Electronic Injury Surveillance System (NEISS) highlights, data and query builder. Published 2024. https://www.cpsc.gov/cgibin/neissquery/home.aspx
- 13.Christenson E.S., Jiang X., Kagan R., Schnatz P. Osteoporosis management in post-menopausal women. Minerva Ginecol. 2012;64:181–194. [PubMed] [Google Scholar]
- 14.Karl J.W., Olson P.R., Rosenwasser M.P. The epidemiology of upper extremity fractures in the United States, 2009. J Orthop Trauma. 2015;29:e242–e244. doi: 10.1097/BOT.0000000000000312. [DOI] [PubMed] [Google Scholar]
- 15.Nagurney J.M., Fleischman W., Han L., Leo-Summers L., Allore H.G., Gill T.M. Emergency department visits without hospitalization are associated with functional decline in older persons. Ann Emerg Med. 2017;69:426–433. doi: 10.1016/j.annemergmed.2016.09.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Moore B.J., Liang L. Agency for Healthcare Research and Quality; Rockville, MD: 2020. Costs of Emergency Department Visits in the United States, 2017. [PubMed] [Google Scholar]
- 17.Cheng R., Maloney A., Moran J., Newman T.H., Gardner E.C. Resistance training as treatment for sarcopenia: Examining sex-related differences in physiology and response. Clin Ther. 2022;44:33–40. doi: 10.1016/j.clinthera.2021.11.012. [DOI] [PubMed] [Google Scholar]