Pickleball Injury Prevention: What Twenty Years in Orthopedics Has Taught Me About Protecting Your Back, Hips, Knees, and Shoulders

I've been practicing orthopedic and sports medicine for two decades, and I've watched pickleball go from a niche pastime to one of the fastest-growing sports in the country. The injuries have grown right along with it. National injury surveillance data shows the estimated number of pickleball-related injuries presenting to U.S. emergency departments climbed from about 1,300 in 2014 to roughly 24,500 in 2023, and hospital admissions rose 257% between 2020 and 2022 alone (Sage Journals, ORS Annual Meeting). A ten-year national analysis using the Consumer Product Safety Commission's injury database found an 88% increase in injury rates since 2020, with fractures and sprains each accounting for about 27% of cases and 91% of injuries occurring in players over age 50 (AOAO).

None of this means you should stop playing. Pickleball is genuinely good for cardiovascular health, balance, and social connection, especially for adults over 50. Racquet and paddle sports are consistently among the best activities for longevity: the Copenhagen City Heart Study found tennis players gained 9.7 years of life expectancy over sedentary adults and badminton players gained 6.2 years, with the authors noting that the social interaction built into these sports may be a key driver of that benefit (Mayo Clinic Proceedings). My goal here is the same goal I have in the exam room: help you understand where the risk actually comes from so you can train around it, instead of finding out the hard way.

What the Injury Data Actually Shows

Pickleball injuries cluster into two buckets: sudden traumatic injuries from falls or hard stops, and slow-building overuse injuries from repetitive load without adequate conditioning.

A prospective study of nearly 1,800 players found a 12-month prevalence of any injury complaint of 68.5%, with 40.8% of players losing time from play and roughly one in three continuing to play through pain (PMC). In that cohort, the knee had the highest injury prevalence at 29.1%, followed by the combined lower leg and foot region at 26.9%, the shoulder at 22.2%, the low back at 19.9%, and the elbow at 18.4%. A separate six-year single-center review of 618 injuries found soft tissue strains made up nearly half of all cases, with rotator cuff injuries the single most common specific diagnosis, followed by low back injuries and calf strains (PMC). At the knee, meniscus tears and MCL sprains from sudden pivoting are far more common than ACL tears, though I still see the occasional ACL injury from a bad landing at the kitchen line.

Sex and age also matter. Men are roughly three times more likely to sustain a muscle strain or joint sprain, while women are roughly three times more likely to sustain a fracture, largely reflecting fall mechanics and bone density after menopause (PubMed). A separate AAOS-presented analysis found a 90-fold increase in pickleball-related fractures over 20 years, concentrated in women 65 and older following falls, even though men were 2.3 times more likely to require hospital admission once fractured (AAOS).

Why Pickleball Injures the Body the Way It Does

A few biomechanical facts explain which injuries occur and why. The ready position holds the hips and knees in a semi-flexed, forward-leaning stance for the entire point, loading the lumbar facet joints and hip abductors continuously. The court is small and almost always hard synthetic surface, so lateral cuts and sudden stops generate high ground-reaction forces through the ankle, knee, and hip, unlike the softer courts common in tennis. Serves and dinks are underhand, but smashes and overhead lobs demand forceful shoulder motion that loads a rotator cuff most players haven't strength-trained in years. And the average player is well into their 50s or 60s, when tendon elasticity, bone density, and reaction time have all declined, so recovery from small mechanical errors is slower than it was at 30.

A recent review of lower extremity injuries in adult pickleball players identified the core, modifiable risk factors clearly: advancing age, prior musculoskeletal injury, inadequate conditioning, and insufficient pre-activity warm-up (Cureus). The other factor I see constantly is ramp-up speed. Patients who go from sedentary to playing three or four times a week within a month or two are at much higher risk for traumatic and stress injuries compared with players who build volume gradually.

Prevention Starts Before You Walk Onto the Court

A proper warm-up is not optional, and it should be dynamic, not static. Save the long holds for after you play. Before you play, spend 5 to 10 minutes on light cardio, then move through arm circles, walking lunges, high knees, and torso rotations. This raises tissue temperature and primes the exact movement patterns your joints are about to perform under load.

Beyond the warm-up, here is the strength work I recommend, organized by the region I see injured most often.

For the Low Back

Most low back pain after pickleball traces to an irritated disc from repetitive rotation, lumbar facet compression from the sustained ready position, or hip weakness that shifts load onto the spine with every lateral push-off.

• Bird dog: On hands and knees, extend one arm and the opposite leg together while keeping the spine neutral. This builds the deep core endurance that protects the lumbar spine during rotation. 2-3 sets of 8-10 reps per side.
• Dead bug: Lying on your back with hips and knees at 90 degrees, slowly lower one arm and the opposite leg toward the floor without letting your low back arch. One of the safest ways to build anti-extension core control.
• Hip hinge with glute bridge: Strengthening the glutes offloads the lumbar spine during the lateral push-offs that dominate pickleball footwork. 2-3 sets of 10-15 reps.
• Thoracic rotation stretch: Improving mid-back rotation reduces the twist your lumbar spine has to absorb during a swing. Do this daily, not just before play.

For the Hip and Knee

Knee injuries in this sport are usually meniscus tears or ligament sprains from pivoting, not contact trauma, and respond well to targeted lateral strength work.

• Side-lying leg lifts and clamshells: These isolate the hip abductors, which stabilize the knee during the constant side-to-side movement pickleball demands. 2-3 sets of 12-15 reps per side.
• Multi-angle lateral lunges: Step out to the side, bend the lead knee while keeping it tracking over the toes, and return. This rehearses the deceleration pattern that causes most meniscus and MCL injuries when done unprepared. 2 sets of 8-10 reps per leg.
• Single-leg balance work: Standing on one leg for 30 seconds, progressing to an unstable surface, builds the proprioception that prevents ankle rolls and awkward, knee-loading falls. This matters more, not less, as you get older.
• Eccentric calf raises: Slowly lowering your heels off a step edge strengthens the Achilles tendon under load, directly relevant given the sharp rise in pickleball-associated Achilles ruptures in players over 50 (OrthoCarolina Research Institute).

For the Shoulder

Rotator cuff tendinopathy and tears are the single most common specific diagnosis I see, and the mechanism is nearly always cumulative overload from repetitive smashes and reaching shots on a cuff that hasn't been conditioned for it.

• Resistance band external and internal rotation: With your elbow tucked at your side and bent to 90 degrees, rotate your forearm outward and inward against light band resistance. The rotator cuff is a small muscle group built for endurance, not heavy load, so aim for 20-30 controlled reps rather than adding weight, 2-3 times a week.
• Scapular retraction and rows: Squeezing the shoulder blades together against band or light dumbbell resistance strengthens the mid-trapezius and rhomboids, which stabilize the shoulder blade and reduce compensatory strain on the rotator cuff.
• Posterior capsule stretch: Bring your arm across your body and gently pull it closer with the opposite hand, holding 20-30 seconds. Tightness here is common in players who favor one-sided shots and contributes to impingement symptoms.
• Dynamic arm circles before play: Small circles progressing to large ones, in both directions, is a simple way to prime the joint capsule before the first serve.

When to Stop and Get Evaluated

Soreness that resolves within 24 hours is normal training adaptation, but a few signs mean it's time to come in rather than push through. See an orthopedic sports medicine physician if you have joint swelling, especially at the knee or shoulder; pain persisting beyond two weeks despite rest; shoulder weakness or an inability to reach overhead comfortably; a specific painful arc where some shoulder positions hurt and others don't; back pain radiating into a leg, or neck pain radiating into an arm; or if you notice yourself changing your mechanics to avoid pain, a reliable sign a structure is failing under load, not just fatigued.

The Bottom Line

Pickleball's injury rates are rising because participation is rising faster than most players' conditioning is keeping up. The fix isn't complicated. Warm up dynamically before every session, build volume gradually rather than jumping from zero to four sessions a week, and spend two or three days a week on targeted strength work for the hips, glutes, core, and rotator cuff. In my experience, the players who do this stay on the court, and the ones who skip it end up in my waiting room.