Pickleball, Sport of the Future Injury?

During a recent pickleball match, Nish Nadaraja, 50, made a quick lunge for the ball. It was just a few feet away, but Mr. Nadaraja, an entrepreneur in Northern California, said he felt his feet tangle and he began falling to the pavement “in slow motion.” He still hoped to brace himself with his knees and make a play with his paddle.

Nope. “I face-planted,” he said.

The pain was mild and Mr. Nadaraja played through it, although his wife (and doubles opponent) thought he should have rested. “I did need antibiotics,” he conceded.

It was another wound stemming from a national sensation that shares a name with a snack or a sandwich topping but that is proving a bit more hazardous than sometimes advertised. As a flock of middle-aged players migrate from tennis or start fresh with an easy-to-learn sport, the aches are defying the game’s low-impact reputation.

Pickleball injuries were on the rise even before the pandemic. One analysis, published in 2019 in The Journal of Emergency Medicine, estimated that there were 19,000 pickleball injuries in 2017, with 90 percent of them affecting people 50 and older.

Part Ping-Pong, tennis, badminton and chess, pickleball involves hitting a whiffle-ball-like sphere with a paddle over a net. The game, which is highly social, is typically played as doubles in a small space like a mini tennis court and requires little running. There’s even a small area near the net known invitingly as the Kitchen. What could go wrong?

“Achilles’ strains or tears, shoulder problems, rotator cuff injuries, lower back problems such as disc injuries, muscle strains,” said Noe Sariban, a pickleball instructor, former pro player and physical therapist who markets himself as the Pickleball Doctor. And, of course, there’s lateral epicondylitis, commonly known as tennis elbow — now pickleball elbow.

“Pickleball kind of sounds like a game with a silly name, but it’s a sport,” Mr. Sariban said. “It’s no bocce ball.”

The number of injuries “grew rapidly” from 2010 to 2019, according to an analysis of emergency-room visits related to pickleball published last year in the journal Injury Epidemiology. The article focused on injuries among people over 60 because players in that demographic accounted for 85 percent of the visits, the study found. The most common injuries were sprains, strains and fractures.

The study found that by 2018 the number of emergency-room visits related to pickleball among people 60 and older equaled the number for tennis. Many pickleball players are older; the average age is 38, but half of all “core” players — meaning devotees — are 55 and above, according to USA Pickleball, which calls itself the sport’s governing body. In general, older bodies are more likely than younger ones to have existing strains, which are easily amplified.

But pickleball is deceptively demanding at any age. It involves quick stops and starts, and lots of lunging and twisting, said Dr. Neil Roth, an orthopedist in Westchester County, N.Y. Overhead shots tear at shoulder joints. And on a small court the effort seems innocuous, so players tend to reach or bend to make a play that is harder on the body than it looks. In tennis, a new player might not think to chase down a distant ball, whereas in pickleball the temptation is greater to bend, reach, charge.

This month, Dr. Roth met with a 53-year-old patient who was experiencing excruciating pain when he lifted his right arm over his head. The injury, from pickleball, turned out to be a labrum tear, a condition that Dr. Roth saw quite often when he worked for the Los Angeles Dodgers and the California Angels; he has also treated cases caused by tennis and swimming.

“You’re absolutely not just sitting around hitting the ball,” Dr. Roth said of pickleball. Players are engaging the “long muscles of the lower legs, the gastrocs, the quads and the hamstrings,” he added.

Stops and starts lead to slips. That helps explain why the largest share of emergency-room injuries identified in the 2021 study fell (as it were) into a category that researchers labeled Slip/Trip/Fall/Dive.

“Most of it is from tripping,” said Dr. Amy Fenoglio, a hand and upper-extremity surgeon at the University of Colorado, where she has seen a surge in pickleball-related wrist fractures in the past 18 months.

Then there’s the Kitchen. Its official name is the nonvolley zone, a seven-foot strip in front of the net on both sides. (An official pickleball court is 44 feet long and 20 feet wide.) Players are not allowed to step foot in the Kitchen, so when a ball heads there a player might bend forward to return a “dink,” a cunning shot that hops over the net and lands in the opponent’s Kitchen.

Mr. Sariban knows the risks firsthand. A former junior college basketball player, he was in a small professional pickleball tournament in January 2018 — perfect Southern California day, a $200 gift certificate for the winner — when he found himself at the edge of the Kitchen.

“I’m reaching to hit a routine rolling volley, one I’ve hit a million times,” he said. “I hit the ball and I feel my back lock up, and in my head I go, ‘Uh-oh.” Within minutes, he had to lie down on the court. “I could barely walk,” he said, adding, “I sat in the car and my wife had to swing my legs around” and into the passenger well. He had herniated two discs. “I thought I was never going to play a sport ever again in my life,” he said.

Since then Mr. Sariban has become conscientious about stretching, and he teaches players at his clinics to do the same, which includes warming up without a paddle before any hitting starts. “It is amazing to me how no one warms up,” he said. “I’ve taught in a lot of states, and it’s the same thing everywhere. Pickleball players are notorious about not warming up.”

Mr. Sariban and other pickleball experts note that the risk of injury isn’t higher than in other sports, but that the perception of risk is lower. And the risks should not discourage participation, say die-hards like Debbie Landa, a tech entrepreneur in her early 50s in San Francisco. Like many, Ms. Landa has taken up pickleball during the pandemic; she now plays five days a week. Among her mentors, she said, was an 82-year-old woman in Palm Springs “who motivated me everyday.”

Ms. Landa has had various pickleball afflictions — pickleball elbow, sore hips — but those come with the sport, she said. The real pains, she said, are the nasty players who “get too aggressive and angry.”

“I tell them: ‘You’ve got to loosen up. You’re playing pickleball — you’re playing a game called pickleball!’” she said.