Pickleball-related Orthopaedic Injury Presentations to a Large Urban Healthcare System From 2015 to 2024

Abstract

Introduction:

Pickleball is the most rapidly growing sport in the United States. No study to date has analyzed the injury burden on a single large urban healthcare system. We hypothesized that the incidence of pickleball-related injuries and presentations to all clinical settings in a single healthcare system, including the emergency department, urgent care, and outpatient clinic, increased markedly over a 10-year period.

Methods:

Deep6 software was used to identify patients using keywords encompassing the gamut of pickleball injuries presenting to the emergency department, urgent care, or outpatient clinic between 2015 and 2024. Charts were retrospectively reviewed, and data were collected regarding patient demographics, injury characteristics, and diagnosis and treatment information.

Results:

Five hundred forty-five patients were included in the study. The mean age was 58.66 years, with 62% of the study population aged 50 to 69 years old. The mean body mass index was 25.46, and 51% of patients were female. The incidence of pickleball injuries increased year after year, including a 386% increase in injuries from 2022 to 2023. Initial encounters were most common in an orthopaedic outpatient clinic (71%). The most common diagnoses in this study were exacerbation of osteoarthritis (16%), meniscus tear (11%), wrist fracture (5.7%), Achilles rupture (5.5%), and epicondylitis (5.1%). Achilles repair (22 patients) and partial meniscectomy (21 patients) were the most common surgeries performed.

Conclusion:

Pickleball injuries continue to rise and are most commonly presenting to outpatient orthopaedic clinics. As pickleball gains popularity, so too will the prevalence of pickleball-related injuries requiring medical attention.

Pickleball is a rapidly growing sport that combines elements of tennis, badminton, and table tennis. According to the Sports & Fitness Industry Association, pickleball has been the fastest growing sport in the United States for the past 3 years with popularity continuing to rise.^1,2 The surge in popularity has come across all age groups. Although historically pickleball has been a sport reserved for older age groups, the age group with the most participants was between 25 and 34 years old.² Pickleball's rise in popularity seems to be due to a number of factors, including ease of learning and access,³ cardiovascular benefits,^4,5 and social interactions.³

Owing to this rapid growth rate, pickleball-related injury incidence has increased. Despite its reputation as a low-impact sport, pickleball involves rapid lateral movements, sudden pivots, and repetitive upper extremity motions all of which contribute to injury risk. Although those with preexisting musculoskeletal conditions or lower baseline fitness levels are susceptible to injuries, acute injuries also occur. This raises concerns about its effect on healthcare systems because these injuries often require medical attention in emergency departments (EDs), urgent care centers, and outpatient clinics.

From the limited data, the most prevalent injuries were either a sprain or strain in men, versus a fracture in women. Injuries also tend to occur more commonly with increasing age. Lower extremities were more often injured than upper extremities.^6,7 Of upper extremity injuries, falls accounted for most of the injuries, with the most common injury being a fracture and the most common anatomic location being the wrist.⁸

Although studies have documented the increasing burden of these injuries in clinical settings, the literature remains limited in key areas. For instance, most available research focuses on presentations to one clinical setting such as the ED,⁹ report low-volume case series,¹⁰ isolate a particular area of the body,^6,11 rely on national databases or patient surveys,¹² or are reviews without high-quality evidence.^13-15 Moreover, studies are currently lacking in establishing definitive incidence rates for a particular healthcare system.

With the sport's growing participation, there has been an increased need for a comprehensive understanding of the epidemiology of these injuries. The aim of this study was to examine the epidemiology of pickleball-related injuries, focusing on their incidence, patterns, and clinical presentations to EDs, urgent cares, and outpatient clinics. By characterizing these injuries, we aim to inform clinicians, policymakers, and sports medicine practitioners on the disease burden on the healthcare system to eventually develop strategies for injury prevention, early recognition, and management, ultimately improving patient outcomes and promoting safe participation in the sport.

Methods

After institutional board review approval, Deep6 artificial intelligence software was used to identify subjects using the keywords “pickleball,” “pickle ball,” “injury,” “fracture,” “sprain,” “strain,” and “contusion.” Boolean operations of “AND” as well as “odds ratio (OR)” were used to create permutations of keywords because phrasing varies within different types of chart notes (eg, pickleball OR pickle ball AND injury). Subject charts were found from any clinical setting within our large urban healthcare system (ie, ED, urgent care, and outpatient clinics). We used the 10-year range for the study between 2015 and 2024.

After excluding charts of patients without pickleball injuries, 545 were found to have injuries directly related to pickleball. Once identified, a retrospective chart review of the subjects was conducted to collect relevant study data. The data points identified were age, sex, body mass index (BMI), date of injury, date of initial presentation, date of most recent presentation, length of follow-up, clinical setting of initial presentation, hand dominance (if mentioned and relevant to the injury), injury laterality, body part, injury type, injury mechanism, diagnosis, imaging obtained, concomitant injuries, treatment, and surgery information where applicable. Once collected, frequency tables were created allowing for statistical analysis.

IBM SPSS Statistics for Macintosh, Version 26.0 (IBM), was used for statistical analysis. Means and medians of patient demographics including age, sex, and BMI were analyzed. Descriptive statistical analysis was used for other data points collecting frequency counts and percentages. Demographic data were complete for all subjects; however, some clinical details varied with patient charts leading to varying sample sizes when conducting individual analysis. For instance, BMI was not recorded for patients whose charts did not mention height and/or weight. A Chi-squared test of independence was used for categorical variables such as difference in injury type between sex and age. The tables of 2 × 2 contingency were used with degrees of freedom 1 for each individual calculation. The Fisher exact test was used for contingency tables that contained cells with counts less than 5.

Results

Study Population

Pickleball-related injuries were found in 545 subject charts. Among these, there were 265 men and 280 women with the mean age of 58.65 ± 13.18 years old and a median age of 60 years old. The age range of subjects lay between 18 and 90 years old with 62% of the study population aged 50 to 69 years old. The other prominent age groups were 70 to 79 at 15%, 40 to 49 at 9%, and 30 to 39 at 7% of the study's population (Figure 1). The mean BMI of subjects was 25.46 ± 4.37, and the median BMI was 24.75 (Table 1).

Figure 1.

Graph depicting the number of subjects in specific age groups who had a pickleball-related injury.

Table 1.

Subject Demographics

Male	265
Female	280
Average age (yrs)	58.66 ± 13.18
Median age (yrs)	60
Average BMI	25.46 ± 4.37
Median BMI	24.75

BMI = body mass index

Injury Rate and Initial Encounters

The rate of pickleball-related injuries from 2015 to 2024 increased exponentially from the year 2022 to 2023 by 386%, and even more patients presented in 2024 (Figure 2). Initial encounters were found to be most common in an orthopaedic outpatient clinic at 71%. Urgent care comprised 8% of initial presentations, EDs made up 10% of initial visits, and nonorthopaedic outpatient clinics accounted for 10% (Figure 3).

Figure 2.

Graph showing pickleball injury occurrences mentioned as initial encounter date in electronic medical records of subjects.

Figure 3.

Graph showing initial encounter locations after pickleball injury.

Injury Distribution

The most common sites of injury were lower extremity (60%), followed by upper extremity (35%), trunk/spine (4.4%), and head/neck injuries (0.6%). Among the lower extremity injuries, the most injured body parts were knee (44%), ankle (26%), foot (9%), hip (8%), hamstring (6%), and toe (2%). Among the upper extremity injuries, the most injured body parts were shoulder (34%), wrist (33%), elbow (22%), and hand (13%) (Figure 4, A).

Figure 4.

Graphs showing (A) injury location occurrences and (B) injury type occurrences.

Injury Types

Accounting for all injury locations, the most prevalent types of injuries were tears (32%), strain/sprains (32%), exacerbations of degenerative disorders (18%), fractures (14%), and contusions (4%) (Figure 4, B).

Of the tears, meniscus tears occurred at the highest rate (39%), followed by glenoid labral tears (15%), rotator cuff tears (12%), anterior cruciate ligament tears (9%), and hamstring tears (9%). The most common locations of strain/sprains were the ankle (20%), elbow (18%), knee (12%), and wrist (12%). Tendinitis (88%) was the leading diagnosis in the strain/sprain category of which epicondylitis made up over one-third of tendinitis cases (35% of tendinitis, 31% of all strains/sprains). Of the degenerative disorders, exacerbations of osteoarthritis (OA) were seen at the highest rate (48%), with knee OA occurring most frequently (56% of OA cases). Shoulder and elbow OA was seen at 18% each, and hip OA was the least common at 8%. Of the fractures, the wrist was the most common location (42%), and distal radius fractures comprised 77% (24/31) of all wrist fractures. Foot fractures comprised 15% of all fractures, knee and hand were 9% of fractures each, and ankle fractures were 8%. Five of the seven fractures (71%) around the knee were tibial plateau fractures. Three patients had proximal humerus fractures (4% of all fractures).

A subanalysis of sex and injury type found that of all injury types, women are more likely to have a fracture (P = 0.032) and men are more likely to have a tear (P = 0.0005). The common injury types of strain/sprain, contusions, and exacerbation of degenerative disorders were not seen to have any statistically significant difference between men and women (P = 0.595, P = 0.61, P = 0.194, respectively) (Table 2).

Table 2.

Chi-squared Analysis of Male vs Female Subjects Within Prominent Injury Types

Injury Type	Male	Female	P Value (P < 0.05)
Strain/sprain	72	83	0.595
Fracture	24	44	0.032a
Contusion	8	11	0.61
Tears	91	64	0.0005a
Degenerative disorders	41	48	0.194
Otherb	29	30	0.98
Total	265	280

^aIndicates a statistically significant difference between sexes.

^bOther includes injuries that were not as commonly seen such as lacerations, dislocations, infections, and neurologic damage.

Injury Diagnoses

The most common diagnoses associated with a pickleball injury were exacerbation of OA (86 patients, 16%), meniscus tear (62 patients, 11%), wrist fracture (31 patients, 5.7%), Achilles rupture (30 patients, 5.5%), and epicondylitis (28 patients, 5.1%).

Injury Mechanism

The most common injury mechanisms were overuse (44%), acute pain while playing (39%), and mechanical falls (17%) (Figure 5). A subanalysis of age and injury mechanisms was done with results in Table 3. The age group of older than 80 had higher odds of injury by mechanical fall than patients between 40 and 49 (OR, 7.2; 95% confidence interval (CI) = 1.52 to 39.87), 50 and 59 (OR, 6.0; 95% CI = 1.70 to 20.54), and 60 and 69 (OR, 3.4; 95% CI = 1.03 to 10.62). The age group of 70 to 79 had higher odds of injury by mechanical fall than age groups 40 to 49 (OR, 4.6; 95% CI = 1.44 to 19.62), 50 to 59 (OR, 3.8; 95% CI = 1.73 to 8.60), and 60 to 69 (OR, 2.1; 95% CI = 1.09 to 4.19). The age group 60 to 69 had a higher odds of injury by overuse than age group 30 to 39 (OR, 2.7; 95% CI = 1.16 to 6.78). All other Fisher exact tests analyzing age groups and injury mechanisms showed no additional statistically significant findings.

Figure 5.

Graph showing the mechanism which led to pickleball injury.

Table 3.

Fisher Exact Test Analysis and Odds Ratios Between Age Groups Within an Injury Mechanism

Age Group 1	Age Group 2	Injury Mechanism	Odds Ratio	95% CI	P Value (P < 0.05)
70-79	40-49	Mechanical fall	4.6	1.44-19.62	0.0041a
80+	40-49	Mechanical fall	7.2	1.52-39.87	0.0049a
70-79	50-59	Mechanical fall	3.8	1.73-8.60	0.0003a
80+	50-59	Mechanical fall		1.70-20.54	0.002a
70-79	60-69	Mechanical fall	2.1	1.09-4.19	0.019a
80+	60-69	Mechanical fall	3.4	1.03-10.62	0.022a
60-69	30-39	Overuse	2.7	1.16-6.78	0.013a

^aIndicates a statistically significant difference between sexes.

Surgery

Similarly to the rate of pickleball injuries, the incidence of surgery after pickleball injury increased 162% between the years of 2022 and 2023, and again by 38% between 2023 and 2024 (Figure 6). The most frequently occurring surgeries after pickleball injury were Achilles repair (22 patients) and partial meniscectomy (21 patients), followed by rotator cuff repair in 12 patients, anterior cruciate ligament reconstruction in 10 patients, and open reduction internal fixation (ORIF) in 9 patients. Proximal hamstring repair, meniscus repair, total hip arthroplasty, and total knee arthroplasty were done in four patients each.

Figure 6.

Graph showing the number of surgeries after pickleball injury per year.

Discussion

Pickleball injuries have risen markedly over the past decade¹⁶, and the sport continues to rise in popularity. This study demonstrates the injury burden on a healthcare system in one of the largest cities in the United States. Within the data collection period, this study found an increase in the number of injuries, presentations for medical care, and surgeries performed year after year. With the highest numbers occurring in 2024 and the continued growth of the sport, we likely have yet to reach the peak of the injury burden on the healthcare system. As such, it is important to characterize these injuries and understand how they present to a healthcare system.

Although most of the patients in this study presented with a pickleball injury to outpatient orthopaedic clinics (71%), patients also presented commonly to the ED, urgent care, and nonorthopaedic clinics. Many studies about pickleball injuries to date isolate presentations to a single clinical setting such as the ED,^6,9 without delineating the proportion of patients presenting to other settings. By isolating presentations solely to the ED, previous studies are missing most of the patients presenting with pickleball settings to other settings. From a healthcare burden standpoint, it is necessary to maximize the percentage of these patients presenting to an outpatient clinic to reduce the burden on acute care settings, where appropriate. Urgent care and ED utilization due to pickleball injuries likely cannot be completely eliminated because many of these injuries occur to weekend warriors when clinics are closed, and some patients require acute services such as fracture reduction and splinting.

Sixty-two percent of the patients in this study were between the ages of 50 and 69. This agrees with previous studies that also showed that most injured patients are older; for instance, Forrester⁹ who found that 90.9% of patients who presented to the ED were older than 50 years. This increased injury risk may be due to a combination of factors, including higher rates of osteoporosis, decreased coordination, and decreased muscle mass.¹⁷ Weiss et al¹⁸ found that in patients older than 60 years presented to the ED and most frequently sustained injuries from mechanical falls. In that study, the most common diagnoses were sprains/strains, followed by fractures, then contusions. Interestingly, in this study that included additional clinical settings, patients in their 60s did not have higher odds of sustaining injuries by mechanical fall, but they did have markedly higher odds of having an overuse injury. Patients aged 70 years and older did show markedly higher odds of injuries from falls when compared with the younger cohorts, which shows some consistency with the previous literature.

This study found that women were more likely to sustain a fracture, and men were more likely to sustain a tear. Other studies agree with these findings because women tend to be more osteoporotic with age and thus more susceptible to fractures.^19,20 Interestingly, this study found no notable difference between men and women regarding sprains/strains, contrasting the existing literature.^18,20 This may be due to that most of the patients in this study presented in the outpatient setting, and thus, the population in this study is not homogenous in comparison with the previous literature.

The mean BMI of patients in this study was more than 25, signifying a population where the average injured pickleball player is overweight. According to the Centers for Disease Control's National Center for Health Statistics, as of 2018, 73.6% of adults older than 20 years were overweight with BMI more than 25.²¹ With such a prevalent obesity epidemic in the United States, it is important to encourage active and healthy lifestyles. Pickleball is a particularly attractive option for previously inactive people due to the low learning curve and lower-impact nature. However, these patients experience increased joint overload and are predisposed to symptomatic OA,²² which was the most common reason to seek medical care in this study.

The most common diagnoses associated with a pickleball injury in this study were exacerbation of OA (16%), meniscus tear (11%), wrist fracture (5.7%), Achilles rupture (5.5%), and epicondylitis (5.1%). Knowing the most common pathologies that require medical care is helpful for counseling players and potentially offers areas of focus regarding pickleball injury prevention programs. Future work may delve deeper into developing sport specific warm up routines or equipment that may help reduce the incidence of developing these pathologies.

Achilles repair and meniscal treatment were the most common surgeries performed in this study. Although Achilles ruptures only made up 5.5% of pickleball injuries, Achilles repair (22 patients) comprised almost one-quarter of all pickleball-related surgeries. Since Achilles tendon ruptures, whether treated surgically or nonsurgically, are associated with prolonged time away from the sport, prevention of these injuries with appropriate warm up and regular physical activity is paramount.¹⁴ Of meniscal treatments performed, 84% were partial meniscectomies versus 16% meniscus repair. This is likely due to a combination of factors, including the age demographic being skewed toward older patients having irreparable tears and these older patients potentially not wanting extended recovery periods after surgery.

This study has its limitations. First, our search may not have captured all patients presenting with pickleball injuries, especially if patient charts had dictation or typographical errors. Second, as a retrospective review, this study is limited by what is reported in the patient encounter, and in certain instances, some data points were unable to be obtained, and it does not encompass long-term outcomes of patients after these injuries. Nonetheless, the present series reports valuable demographic and clinical characteristics of patients sustaining pickleball injuries. Third, this study does not delve into the specifics of each injury, nor does it determine whether there are aspects of these injuries that are unique to pickleball or merely similar to the injuries sustained in similar sports.

There are several potential areas for future study. First, there continues to be a paucity of longitudinal studies tracking injury outcomes, rehabilitation success, or recurrence rates in pickleball players. Second, comparative analyses between pickleball and other racquet sports, such as tennis or badminton, remain underdeveloped, leaving gaps in understanding whether pickleball confers unique injury risks or shares similar patterns with related sports. Third, limited attention has been given to potential preventive strategies, including biomechanical assessments, equipment modifications, or training interventions that could mitigate injury risks, particularly in older players. Other sports have had success in prevention programs,^12,23,24 as well as with protective equipment.^13,20

As pickleball continues to rise in popularity, so too will the prevalence of pickleball-related injuries²⁵ requiring medical attention. This study helps to delineate important patient and injury characteristics related to pickleball.

Conclusion

Injuries associated with pickleball are increasing in accordance with the sport's rise in popularity. Previous studies have either isolated presentations to the ED, been low in sample size, or focus on a particular injury or body part. To date, no study has analyzed pickleball injury presentations to all clinical settings within a single healthcare system. This study reports all pickleball-related injuries that required medical attention at our large urban healthcare system. This is the first study to note that 71% of patients present in the outpatient orthopaedic clinic setting, demonstrating that previous studies that isolate the ED exclude most of the patients with pickleball injuries. This study is also the first to report the most common injuries and surgeries performed because of pickleball-related pathology.