Pickleball Injuries: A Sports Chiropractor’s Guide to Staying in the Game

So you just got off the courts at Meador Park, and your elbow is throbbing. Or your calf felt like someone kicked it when you lunged for that drop shot you probably should have let go. Or your knee buckled mid-pivot and you're really hoping no one saw. If any of that sounds familiar, you're in pretty good company.

The five injuries we see over and over in pickleball players are pickleball elbow, Achilles tendon strains and ruptures, rotator cuff pain, knee ligament tweaks from cutting and pivoting, and wrist or hip fractures from falls. Pickleball-related ER visits roughly doubled between 2014 and 2023, with falls causing more than 60 percent of them. Here's the thing though, most of these injuries are pretty preventable if you know what's actually happening under the hood. And almost all of them give you warning signs long before they sideline you. You just have to know what you're listening for.

Below, we'll walk through each one, what's going on biomechanically, and what actually works to fix it. Skip ahead if one of these is screaming your name.

Wait, Is Pickleball Even That Hard On the Body?

This is the question I get all the time, and honestly, the answer surprised me when I first dug into it. The court is small. The paddle is light. The ball doesn't even bounce that high. It feels like a sport designed to be easy on the body. So why is it putting people in the ER more than tennis at this point?

Turns out, the court being smaller doesn't actually help. Researchers checked, and there's no real correlation between court size and injury rates. What matters is the movement pattern. Quick stops, side-to-side cuts, overhead reaches, and forward lunges, done over and over, often by people whose bodies haven't been prepped for that kind of demand. The light paddle and small court don't change any of that.

The injuries we see split into two buckets:

• Acute stuff. Something happens suddenly. You roll an ankle, you catch yourself wrong on a fall, you feel a "pop" in your calf. Falls drive most of these.
• The slow burn. Pain that builds over weeks. The elbow that's been nagging you since March. The shoulder that aches every Saturday night. One study of tournament players found about 78 percent of their reported injuries came from this category, not from a single dramatic event.

This distinction matters more than people think. Acute injuries need protection and assessment first. The slow-burn stuff almost never resolves with rest alone, which is the part most people get wrong. We'll get to that.

1. Pickleball Elbow (Also Known as Tennis Elbow)

Quick branding aside: "pickleball elbow" and "tennis elbow" are the same thing. The clinical name is lateral elbow tendinopathy, but no one calls it that at the dinner table.

The muscles that extend your wrist all attach to a small bump on the outside of your elbow. Every backhand, every blocked volley, every time you stabilize the paddle against a hard shot, those muscles pull on that attachment point. When the tendon can't keep up with how much load you're throwing at it, the tissue gets unhappy. Stays unhappy. Eventually screams.

This is the second most-injured area in pickleball survey data, right after the knee.

Why it happens (and yes, I've had it too)

• Your paddle grip is too small. Sounds minor. It's not. A grip that's too small forces your forearm muscles to work overtime just to keep the handle from twisting in your hand.
• You're hitting the ball late. When contact happens behind your body, the load shifts from your shoulder muscles (which can handle it) down to your elbow (which can't, at least not for long).
• You jumped your volume. Went from two sessions a week at Classic's Yard to four because the league started up. That's a 100 percent increase in tissue exposure, and tendons adapt embarrassingly slowly.

What actually helps

The protocol is unglamorous. Grab a light weight (start with 2 to 3 pounds). Rest your forearm on a table, wrist hanging off the edge, palm down. Slowly lower the weight over a count of 4, then use your other hand to bring it back up. Three sets of 15, once a day. You want mild discomfort during the exercise, not pain that lingers afterward.

A counterforce brace can help take some load off while the tissue rebuilds. But please don't try to just rest your way out of this one. I see people take a month off, feel better, come back, and the pain returns within two sessions. Rest doesn't fix the capacity problem. Loading it (carefully) does.

2. Achilles Tendon Strains and Ruptures

This is the one that scares me the most, and I think it should scare you a little too. Orthopedic clinics started noticing a pattern around 2016. The pickleball-related Achilles ruptures coming through their doors looked different than the usual Achilles patients. Specifically, they were about 16 years older on average, and they were significantly more likely to need surgery to fix.

One study from a multi-state orthopedic group found that the average age for a pickleball Achilles rupture was 64.5 years old, compared to 48.6 for non-pickleball Achilles patients. Roughly two-thirds of the pickleball cases ended up in surgery, versus less than half of the non-pickleball ones. A separate study from Brigham and Women's looked at almost 200 pickleball foot and ankle injuries and found Achilles rupture was the single most common diagnosis. The most common way it happened? Running or lunging forward.

So, the classic pickleball movement, the explosive forward push-off out of the kitchen, is the exact loading pattern that's putting an older tendon past its capacity.

Why it happens

The Achilles takes forces of about 7 to 8 times your body weight during athletic push-offs. After about age 40, the tendon gets less elastic and gets less blood flow than it had in your 30s. Mix in an explosive lunge after standing still in the kitchen for several seconds (which is, you know, the entire sport), and you've got a setup for the tissue to give out.

What actually helps

You want to actively build calf and Achilles capacity, not just stretch. A pretty massive evidence review (covering more than 500 tendinopathy studies) found that combining concentric and eccentric strengthening gives the best results across pretty much every tendon in the body, Achilles included.

3. Rotator Cuff Pain (a.k.a. Why Your Shoulder Hates Serving)

Your rotator cuff is four small muscles that wrap around your shoulder and keep the ball part from sliding around in its socket. Useful job. Every overhead serve, every put-away, every time you reach up for a high ball, those muscles are doing their thing. When they get overloaded, you get pain when you reach, pain when you sleep on that side, and that distinctive ache lifting anything away from your body.

Tournament-level survey data puts shoulder and upper arm injuries at around 17 percent of all pickleball complaints. So it's not the biggest category, but it's also not small.

Why it happens

• Your shoulder blade isn't doing its job. The big muscles on your back are supposed to control where your shoulder blade sits during overhead motion. When they're underdeveloped or sleepy, the smaller cuff muscles have to pick up the slack, and they break down.
• Your mid-back is stiff. If your upper spine doesn't rotate well (and most of us are stiff there from sitting), your shoulder has to find that range somewhere, which means stressing tissues that weren't designed to provide it.
• Your desk and your pillow are working against you all day, so by the time you serve, your shoulder is already at a disadvantage.

What actually helps

There's a brand new clinical practice guideline from 2025 (the kind of document that pulls together all the available research and tells clinicians what's actually supported) that gives the highest recommendation to exercise therapy combining rotator cuff strengthening, shoulder blade control work, and progressive loading. Injections and surgery are way down the list for tendinopathy without a full tear.

Practical version: banded external rotation (3 sets of 12 per side, twice a week), prone Y and T raises for the shoulder blade stabilizers, and wall slides to train overhead motion in a controlled range. Build volume for four to six weeks before you start ramping up intensity. Your shoulder will thank you.

4. Knee Ligament Stuff (Mostly MCL Sprains)

The knee is the most-reported injury site in pickleball survey research. About 23 percent of reported injuries are here. The story is almost always the same. You plant your foot, you change direction, your lower leg gets pushed one way while your thigh goes another, and the ligament on the inside of your knee (the MCL) takes the brunt of it.

Why it happens

• Your hips aren't strong enough, so your knees are doing direction-changing work they shouldn't be doing.
• You're wearing running shoes. I'm sorry. I know they're comfortable. They're built for moving in a straight line. The sole doesn't give you any lateral stability, and pickleball is basically all lateral movement.
• The court grabs your foot when it shouldn't. Indoor courts with sticky surfaces, or outdoor courts with dew, change how your foot interacts with the ground in ways your nervous system isn't expecting.

What actually helps

Knee resilience comes from hip strength (single-leg deadlifts, lateral band walks, step-ups), quad strength (split squats, leg press), and balance work that challenges you in multiple directions. And yes, you need actual court shoes for indoor play. I won't keep harping on this. Mostly.

5. Falls, and the Wrist and Hip Fractures They Cause

Here's the stat that should get everyone's attention. Falls cause the majority of pickleball injuries that end up in the ER. A 2021 study of senior pickleball and tennis injuries found slip/trip/fall/dive mechanisms drove 63 percent of pickleball-related ED visits. A newer 2025 analysis showed older players are about 2.1 times more likely to fall during play than younger players. And women are nearly three times more likely to break a wrist when it happens.

Wrist fractures happen when you throw a hand out to catch yourself. Hip fractures happen on direct impact, often after a backward step or a quick spin gone wrong. Both are serious. Hip fractures in players over 65 carry real consequences for long-term independence, not just for the rest of the pickleball season.

Why it happens

• Single-leg balance degrades with age. This is one of those things nobody really talks about until they've already fallen. The good news is it's very trainable.
• Backpedaling for a lob. Most players never practice moving backward, so their nervous system isn't ready for it when the ball goes overhead.
• You can't decelerate without falling into the deceleration. Quick stopping is a skill that requires strength to back it up.

What actually helps

Fall prevention research in older adults pretty consistently shows that multi-component programs (combining strength, balance, and gait challenges) reduce fall risk in a meaningful way. The catch is that it has to be progressive and consistent. Two weeks of balance drills isn't going to do anything you'll notice. Eight to twelve weeks of regular work absolutely will.

So What Do You Actually Do If You're Already Hurt?

If something happened suddenly, the right move is to stop, get it iced, and get it looked at. I'd rather you take an unnecessary trip to the ER than try to walk off a fracture or an Achilles tear.

For the slow-burn stuff (the elbow that's been nagging for weeks, the shoulder that aches every Sunday, the knee that just feels off), here's where most people get it backward. Rest feels like the obvious answer. And for the first day or two, sure, back off. But if you take three weeks off and come back to the same volume, the same pain is going to come right back. The underlying capacity issue didn't go anywhere just because you stayed off the court.

What actually works for tendon-driven pain is loaded rehab with the right exercise selection, the right dose, and a return-to-play plan that respects how slowly tendons remodel. I won't pretend you can DIY all of this perfectly. Honestly, even as someone who treats this stuff for a living, I tweaked my own elbow last spring and had to follow my own advice longer than I wanted to. There's no shortcut, but there's also no reason to white-knuckle it alone.

Sources

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