May 2021

Pickleball-related Injuries Involving the Lower Extremity Treated in Emergency Departments

Photographs are courtesy of Alan Herzberg, Jr.

By Mathias B. Forrester, BS

Background: Pickleball is a paddle sport that combines many of the elements of tennis, badminton, and ping-pong. It is reported to be increasingly popular in the United States (US), particularly among older adults. There is limited published information on pickleball-related injuries, including those involving the lower extremity. The objective of this study was to describe pickleball-related injuries involving the lower extremity treated in US emergency departments (EDs).

Methods: An analysis was performed of pickleball-related injuries involving the lower extremity using data from the National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission (CPSC) during 2000-2019.

Results: A total of 172 pickleball-related injuries involving the lower extremity were identified, resulting in a national estimate of 10,504 such injuries. Of the estimated injuries, 6.6% occurred during 2000-2011, 14.5% during 2012-2015, and 78.9% during 2016-2019. Patients age 60 years or older accounted for 78.7% of the patients; 62.2% were male. The most common injuries were sprain or strain (76.3%) and fracture (7.6%). The most frequently affected body part was the lower leg (43.9%), ankle (21.3%), and knee (19.3%). The patient was treated or evaluated and released from the ED in 98.8% of the estimated injuries.

Conclusions: Pickleball-related injuries involving the lower extremity have been increasing in recent years. Patients with injuries tended to be older and male. Their injuries were most frequently a sprain or strain and affected the lower leg. The majority of patients were treated or evaluated at an ED and then released.

Pickleball is a paddle sport that combines elements of tennis, badminton, and ping-pong. It can be played indoors and outdoors on a badminton-sized court with a modified tennis net. Pickleball uses a paddle larger than a ping-pong paddle but smaller than a tennis racquet and a plastic ball with holes similar to a whiffle ball. It can be played as singles or doubles (two players to a team).1,2

Pickleball is becoming increasingly popular in the United States (US).2 According to the Sports and Fitness Industry Association (SFIA) 2019 Pickleball Participant Report, pickleball had 3.3 million players in the United States (US). The growth rate for all players from 2015 to 2018 was 29.1%.1 The sport is popular with community centers, physical education classes, YMCA facilities, and retirement communities.1 The sport is particularly popular among older adults because it is a low-impact sport, easy to learn, fosters positive social interaction, and provides health benefits.3-5

Injuries may occur while playing pickleball. Anecdotal reports have described injuries such as sprains, strains, and fractures to the limbs; tendonitis or tendon rupture; plantar fasciitis; rotator-cuff injuries; and blunt trauma to the head.3 A study of an estimated 19,012 pickleball-related injuries treated at US emergency departments (EDs) during 2001-2017 found the most frequently reported injuries to be sprain or strain, fracture, contusion or abrasion, and laceration. This study also reported that the most commonly affected body part was the lower extremity, comprising 32.0% of the estimated pickleball-related injuries.6 With the increasing popularity of this sport, the number of injuries might be expected to increase.

The objective of this study was to characterize pickleball-related injuries involving the lower extremity treated in US EDs.

Methods

Figure 1. Annual estimated number of pickleball-related injuries involving the lower extremity treated in United States emergency departments, National Electronic Injury Surveillance System (NEISS)

Data were downloaded from the National Electronic Injury Surveillance System (NEISS) website at https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx. The NEISS is operated by the US Consumer Product Safety Commission (CPSC). The NEISS collects data on consumer product-related injuries in the US from the EDs of approximately 100 hospitals as a probabilistic sample of the more than 5,000 hospitals with EDs in the US. The NEISS is a stratified sample based on ED size and geographic location. Professional NEISS coders view the medical charts at the selected hospitals and collect and code information including patient demographics and basic injury information, such as injury diagnosis, body parts affected, and location where the injury occurred as well as a brief narrative describing the incident.7,8 Data are publicly available and de-identified; therefore, the study is exempt from institutional review board approval.

Cases were pickleball-related injuries involving the lower extremity reported to the NEISS during 2000-2019. The NEISS database contains three numeric fields (Product_1, Product_2, Product_3) for coding the product(s) involved in an injury. There are a number of product codes for various sports and other physical activities; however, there is no product code for pickleball. In order to identify pickleball-related injuries, all records with a Narrative text field containing the letter groups “pic” and “bal” were identified. For this subset of records, the Narrative fields were individually examined to determine whether they indicated the injury was related to pickleball. Those records that indicated the injury was related to pickleball were included in the study.

The NEISS database also has the Body_Part numeric field for coding the body part that was injured. Only those records with body part codes for the lower extremity [Knee; Leg, lower (not including knee or ankle); Ankle; Leg, upper; Foot; Toe; Lower leg (Old)] were included in the study.

The distribution of cases and national injury estimates were determined for treatment year and season, patient age and sex, location where the injury occurred, disposition, diagnosis, and affected body part. National injury estimates were calculated by summing the values in the Weight numeric field in the publicly available NEISS database. The 95% confidence intervals (CIs) were calculated for the estimates. The CPSC considers an estimate unstable and potentially unreliable when the number of records used is <20 or the estimate is <1,200.7 For those variable subgroups where the estimate was < 1,200, 95% CIs were not calculated.

Results

Table 1. Selected characteristics of pickleball-related injuries involving the lower extremity treated in United States emergency departments, National Electronic Injury Surveillance System, 2000-2019

A total of 172 pickleball-related injuries involving the lower extremity were identified, resulting in a national estimate of 10,504 (95% CI 7,736 – 13,273) lower extremity injuries, or 26.7% of the 39,368 total estimated pickleball-related injuries involving any body part. (The only body part representing a higher proportion of total estimated injuries was the upper extremity, accounting for 11,703 or 29.7% of the total estimated injuries.) Figure 1 shows the annual estimate of pickleball-related injuries involving the lower extremity, and Table 1 shows the number of injuries by 4-year period. During 2000-2013, the annual estimate ranged between 0 and 168 injuries. The annual estimate increased each year after 2013, from 291 injuries in 2014 to 3,175 injuries in 2019, an increase of almost 11 times over the 6-year period. The highest proportion of injuries occurred during December-February followed by March-May.

Table 1 presents various characteristics of pickleball-related injuries involving the lower extremity. The highest proportion of patients was age 60-69 years followed by 70 years or older; patients age 60 years or older accounted for 8,271 (78.7%) of the estimated injuries. The majority of patients were male. Most of the injuries occurred at a sports or recreational facility. Almost all of the patients were treated or examined in the ED and released.

Table 2 shows the type of injury. Most of the injuries were a sprain or strain followed by a fracture and contusion or abrasion. The affected body part was most often the lower leg (not including the knee or ankle) followed by the ankle and knee.

Discussion

This study describes pickleball-related injuries involving the lower extremity treated in US EDs over a 20-year period. Like many other sports, injuries may occur while playing pickleball. However, there is limited information on pickleball-related injuries, including injuries involving the lower extremity.3,6

While the annual estimated number of pickleball-related injuries involving the lower extremity reported during 2000-2013 was relatively small, the estimated number of injuries increased each year afterward, with the estimated number of injuries in 2019 representing 30.2% of all estimated injuries involving the lower extremity during the 20-year time period and being almost 11 times that reported during 2014. The recent increase in pickleball-related injuries involving the lower extremity may be related to an increasing number of persons playing the sport.1,2 If this increase in participation continues, then an increasing number of injuries may be expected in the future.

Patients with pickleball-related injuries involving the lower extremity tended to be older, with patients age 60 years or older accounting for 78.7% of the patients. This pattern might be expected considering that pickleball is particularly popular among older adults.3-5 According to the SFIA 2019 Pickleball Participant Report, 64% of core players (persons who play 8 or more times per year) were age 55 years or older.1

The majority (62.2%) of the patients were male. This proportion is almost the same as the SFIA 2019 Pickleball Participant Report, which noted 62% of pickleball participants to be men.1

Table 2. Type of injury of pickleball-related injuries involving the lower extremity treated in United States emergency departments, National Electronic Injury Surveillance System, 2000-2019

The most common lower extremity injuries associated with pickleball were a sprain or strain (76.3%), and the part of the lower extremity most often injured was the lower leg (43.9%) followed by the ankle (21.3%) and knee (19.3%). When the specific diagnosis and body part involved in an injury were examined together, the most frequently reported injuries were sprain or strain of the lower leg (39.2%) followed by the ankle (18.5%) and knee (9.8%). The majority (98.8%) of the patients were treated or evaluated in the ED and then released. This might be expected, considering that, for the most part, sprains and strains and the other diagnoses reported with injuries of the lower extremity (fracture, contusion or abrasion, hematoma, dislocation) might not require extensive treatment at a healthcare facility.

There are limitations to this study. Cases were identified by searching for “pic” and “bal” in the electronic record narrative. Pickleball-related injuries where these terms were not recorded in the narrative would not have been included in this investigation. Only those injuries treated at an ED were included. The number of pickleball-related injuries involving the lower extremity not seen at an ED is unknown. In addition, there were relatively few cases. This is particularly important when calculating estimates, which may be unstable and potentially unreliable when a small number of cases are being examined.

In conclusion, this study found that pickleball-related injuries involving the lower extremity have been increasing in recent years. Patients with such injuries tended to be older and male. Their injuries were most often a sprain or strain and affected the lower leg. Most patients were treated or evaluated at an ED and then released.

Mathias B. Forrester, BS, is an independent researcher in Austin, Texas. Now retired, he previously performed public health research for various university and government programs for 33 years.

REFERENCES
  1. USA Pickleball Association. 2020 pickleball fact sheet. Available at https://usapickleball.org/wp-content/uploads/2020/03/2020-FAct-Sheet-3_30_20.pdf. Accessed March 1, 2021.
  2. Loudin A. Pickleball: The fastest growing sport you’ve never heard of. NBC News. April 21, 2019. Available at https://www.nbcnews.com/better/lifestyle/pickleball-fastest-growing-sport-you-ve-never-heard-ncna992106. Accessed March 1, 2021.
  3. Quail MT. Caring for patients with pickleball injuries. Nursing. 2019;49(4):16-17.
  4. Casper JM, Jeon JH. Psychological connection to pickleball: assessing motives and participation in older adults. J Aging Phys Act 2018:Online ahead of print. doi: 10.1123/japa.2017-0381.
  5. Ryu J, Yang H, Kim AC, et al. Understanding pickleball as a new leisure pursuit among older adults. Educ Gerontol. 2018;44:128-138.
  6. Forrester MB. Pickleball-related injuries treated in emergency departments. J Emerg Med. 2020;58(2):275-279.
  7. United States Consumer Product Safety Commission. National Electronic Injury Surveillance System (NEISS). Available at https://www.cpsc.gov/Research–Statistics/NEISS-Injury-Data/Explanation-Of-NEISS-Estimates-Obtained-Through-The-CPSC-Website. Accessed March 1, 2020.
  8. United States Consumer Product Safety Commission. NEISS Coding Manual. January 2019. Available at https://www.cpsc.gov/s3fs-public/2019_NEISS_Coding_Manual.pdf. Accessed March 1, 2021.

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