Pickleball-Related Geriatric Fractures and Pediatric Equipment-Related Injuries Are Increasing in Emergency Departments Across the United States

Purpose

To evaluate the epidemiology, prevalence, and mechanism of injury of pickleball-related injuries in patients presenting to emergency departments in the United States.

Methods

Data between 2004 and 2023 from the National Electronic Injury Surveillance System were analyzed for racquetball-related injuries. The data set was screened for pickleball-related injuries using keywords. Data included body part, diagnosis, mechanism of injury, and disposition. Calculations used corresponding hospital sample weights for national estimates (NEs). Patients were divided into the following age groups: pediatric (<18 years), 19 to 39 years, 40 to 59 years, and 60 years or older.

Results

A total of 1,714 injuries (NE, 99,816 [98.8%]) were included. The most commonly injured body locations were the upper trunk (n = 232) (NE, 14,884 [13.5%]), head (n = 226) (NE, 12,990 [13.2%]), and knee (n = 188) (NE, 10,700 [10.9%]). The most identified final diagnoses were fracture (n = 493) (NE, 27,493 [28.7%]), sprain/strain (n = 423) (NE, 25,237 [24.7%]), internal organ damage (n = 168) (NE, 10,050 [9.8%]), and contusion (n = 163) (NE, 9,573 [9.5%]). The most identified mechanisms of injury were impact with the floor (n = 856) (NE, 50,797 [49.9%]), exertional cardiovascular event (n = 244) (NE, 15,796 [14.2%]), and non-contact movement (n = 222) (NE, 12,936 [13.0%]). Pediatric patients had the highest proportion of head injuries (NE, 222 [16.9%]) and injuries from equipment (NE, 634 [32.2%]). The group aged 60 years or older had the highest proportion of wrist injuries (NE, 10,302 [13.0%]), fractures (NE, 17,802 [32.8%]), and injuries cause by impact with the floor (NE, 43,592 [56.1%]). Additionally, this group had the highest proportion of upper trunk injuries (NE, 12,947 [15.4%]) and exertional chest pain (NE, 13,789 [16.2%]).

Conclusions

Pickleball injuries most frequently involved the upper trunk, head, and knee, with fractures and sprains/strains being the most common diagnoses. Nearly half of all pickleball injuries resulted from impacts with the floor. Pediatric patients had a higher proportion of head injuries and equipment-related trauma, whereas older adults (≥60 years) were more prone to wrist and upper trunk injuries, fractures, and exertional chest pain.

Level of Evidence

Level IV, retrospective epidemiologic case series.

Pickleball has become the fastest-growing sport in the United States, with the Association of Pickleball Players estimating 36.5 million athletes nationally and the sport showing a 223.5% growth rate from 2020 to 2023. Moreover, national surveys by the Sports & Fitness Industry Association report that pickleball athletes include all ages and demographic groups, with the two largest age brackets being greater than 55 years and 18 to 34 years of age, comprising 19.8% and 18.5%, respectively. The rapid growth in pickleball activity has subsequently lead to an increase in associated musculoskeletal (MSK) injuries, with a retrospective analysis by Ghattas et al. showing a 90-fold increase in pickleball-related injuries from 2002 to 2022. This increase in acute MSK injuries carries significant financial implications, burdening the U.S. health care system with approximately $500 million in annual medical costs.

Several studies have evaluated the incidence as well as common mechanisms of injury (MOIs) regarding pickleball in adult and pediatric athletes. Kasper et al. assessed pickleball-related upper extremity injuries and found that falling on an outstretched hand was the most common MOI. Although most patients were managed nonoperatively, those older than 65 years were significantly more likely to require surgical intervention. In a national analysis, Weiss et al. evaluated pickleball-related injuries in elderly athletes, aged 60 years or older, and found that although older male athletes were significantly more likely to sustain an injury, female athletes were 3 times more likely to experience a fracture and 9 times more likely to sustain a wrist fracture. More recent studies, including those by Boroumand et al. and Kay et al., have used broad age groups (pediatric, adult, geriatric) to describe pickleball injury trends. However, the physiology associated with age differences influences injury patterns, and more granular stratifications may be required to implement age-specific recommendations to decrease injury burden.

Most of the existing literature assessing pickleball-related injuries is limited by small sample sizes and lack of statistical power. Moreover, the available national analyses have all evaluated specific demographic characteristics and diagnoses, providing an incomplete and non-comprehensive evaluation of pickleball-related injuries. Therefore, the purpose of this study was to evaluate the epidemiology, prevalence, and MOI of pickleball-related injuries in patients presenting to emergency departments (EDs) in the United States. We hypothesized that given the high prevalence of older adult athletes and advanced age’s effect on deteriorating MSK health, older age groups would have increases in both acute and chronic injuries when compared with younger age groups.

Methods

Data Collection

The National Electronic Injury Surveillance System (NEISS) database is a publicly available data set from the Consumer Product Safety Commission that represents over 5,000 EDs and 100 hospitals nationally that offer 24-hour services and at least 6 admitting beds. The data set provided variables including date of presentation, age, sex, race, body part, and final diagnosis, as well as a narrative written by a health care provider. Each NEISS record contains a 400-character narrative text field derived from ED records. This narrative provides detailed comments on the patient, associated activity, sequence of events, diagnoses, affected body parts, and other pertinent information. On the basis of the capacity of each respective hospital, each data point was given a statistical sample weight that was used to calculate an accurate national estimate (NE) to represent national trends.

Because the NEISS database does not have a dedicated pickleball category, all injuries from January 1, 2004, to December 31, 2023 (N = 7,278,545) were selected using a computer-assisted search in the narrative text. Narrative entries containing the words “pickleball,” “pickle ball,” “pickle racket,” “pickle racquet,” and “pickle,” as well as the commonly misspelled words “pickelball” and “pickel,” were queried. The utility of this methodology was verified by several other analyses. ^,^, These narratives were reviewed by the first 2 authors (P.M.L., R.N.) to identify the MOI and ensure that the injury occurred from a pickleball-related incident. If the event of disagreement on the interpretation of a narrative, the senior author (D.P.T.) was consulted. Trends were further substratified by sex and age. Age was categorized into 4 groups, including pediatric patients (<18 years), young adults (18-39 years), middle-aged adults (40-59 years), and geriatric patients (≥60 years), which were similarly defined in previous studies. MOIs were categorized as impact with the floor, ankle rolling, non-contact movement, overhead swinging movement, injury with equipment (ball, paddle, etc.), injury with another player, injury with terrain (net, pole, bleachers, etc.), or exertional cardiovascular event. If narratives provided insufficient detail or the exact mechanism was unclear, the MOI was classified as “not specified” (e.g., injured while playing pickleball at the park).

Exclusion Criteria

Narratives describing non-pickleball-related injuries were excluded. Examples include injuries that did not occur while actively playing pickleball (e.g. injured while walking to play pickleball), as well as secondary injuries associated with another primary mechanism (e.g., initial injury while playing volleyball, exacerbated by playing pickleball).

Statistical Analysis

Statistical analyses were performed using IBM SPSS software (version 29.0; IBM, Armonk, NY). NEs were calculated by multiplying the associated statistical weight of the reporting hospital by each queried raw data point. Trends in NEs for overall injuries, injury diagnoses, and MOIs were assessed using linear regressions. Similarly, linear and logistic regression analyses were conducted to evaluate for associations between age groups and sex while confounding variables including race, treatment location, and disposition were controlled for. Categorical variables were analyzed using the χ ² test. The Holm P value adjustment method was used in post hoc analysis. The level of statistical significance was set at P <.05.

Results

Overall Trends Among All Pickleball-Related Injuries

There were a total of 1,735 pickleball-related injuries (NE, 100,914) between 2004 and 2023. After application of the inclusion and exclusion criteria, 1,714 injuries (NE, 99,816 [98.8%]) were included for analysis. The average patient age was 64.81 ± 13.146 years. The median age was 67 years. A total of 1,405 patients (NE, 80,480 [80.6%]) were discharged home and 266 (NE, 16,612 [16.6%]) were admitted for further treatment. There were 868 male athletes (NE, 50,925 [50.6%]) and 845 female athletes (NE, 48,891 [49.3%]). There were 673 white patients (NE, 33,013 [39.3%]), 604 African American patients (NE, 27,348 [35.2%]), 20 Asian American patients (NE, 574 [1.2%]), and 8 patients whose race was classified as “other” (NE, 167). Table 1 presents the distribution of athletes by race, and Figure 1 illustrates injury distributions based on age groups. Figures 2 and 3 illustrate the injury locations and final diagnoses, respectively, stratified by age group.

Table 1

Distribution of Pickleball Injuries by Race According to National Electronic Injury Surveillance System (2004-2023)

	Count	National Estimate	Weighted %
Race
White	655	33,013	33.1
Black or African American	27	724	0.7
Asian	20	574	0.6
American Indian or Alaska Native	8	167	0.1
Native Hawaiian or Pacific Islander	1	16	0.0
Other	1,003	65,323	65.5
Total	1,714	99,817	100

Image, AltText currently not available — Fig 1

The upper trunk was the most commonly injured body location, accounting for 232 of all injuries (NE, 14,884 [13.5%]). The head was the second most commonly injured body location, accounting for 226 of all injuries (NE, 12,990 [13.2%]). The knee was the third most commonly injured body location, accounting for 188 of all injuries (NE, 10,700 [10.9%]). Table 2 presents the distribution of injury locations among all age groups.

Table 2

Distribution of Pickleball Injuries by Body Part According to National Electronic Injury Surveillance System (2004-2023)

	Count	National Estimate	Weighted %
Body part
Upper trunk	232	14,884	13.3
Head	226	12,990	11.6
Lower trunk	180	10,822	9.6
Wrist	188	10,700	9.5
Lower leg	180	10,546	9.4
Face	129	6,693	6.0
Knee	122	6,594	5.9
Shoulder	93	5,608	5.0
Ankle	103	5,339	4.8
Lower arm	86	5,318	4.7
Multiple body parts	76	4,760	4.2
Finger	56	2,969	2.6
Elbow	43	2,515	2.3
Foot	45	2,412	2.2
Upper arm	37	2,069	1.8
Hand	32	1,910	1.7
Neck	22	1,627	1.5
Upper leg	19	1,591	1.4
Eyeball	16	910	0.8
Mouth	8	902	0.8
Toe	10	569	0.5
Pubic region	3	50	0.1
Unknown	10	390	0.3
Total	1,933	112,168	100