The sport that congratulates itself for being gentle has an upper-limb problem, and American emergency departments have been keeping the books. Between 2014 and 2023, a team led by Kevin Valdes at Kansas City University College of Osteopathic Medicine estimated 14,916 pickleball-related injuries to the shoulder, upper arm, elbow and forearm serious enough to reach an ER. More than four-fifths of them happened to people over 60. Nearly three-fifths happened to women. Fractures were not a side-story. They were the main event.
That is the uncomfortable centre of “Pickleball Pains,” a descriptive epidemiology paper published in June in the *Journal of Orthopaedic Experience & Innovation* and brought back into the news on 9 November by Healio. The authors are not arguing that pickleball should be packed away. They are arguing that the people the sport is proudest of attracting — older players, and older women in particular — are the ones paying the injury bill, and that the bill is heavier than the “low-impact” sales pitch has ever admitted.
The national estimate underneath those percentages is worth unpacking, because the headline numbers travel faster than the caveats. Across the same decade, NEISS — the United States Consumer Product Safety Commission’s emergency-department surveillance system — produced a weighted estimate of 66,350 pickleball-related injuries of any kind. Valdes and colleagues isolated the upper-limb share at 14,916, or 22.5 per cent, which works out at about 1,491 such injuries a year. The mean age of those patients was 67.1. Players over 60 accounted for 83.1 per cent of the upper-limb cases (12,389). Women accounted for 59.0 per cent (8,796) against 41.0 per cent for men (6,120). The shoulder was the most commonly injured region, at 36.8 per cent on the weighted figures, with the forearm close behind at 35.1 per cent.
Fractures made up 58.6 per cent of the upper-limb injuries — 8,747 of them, in the weighted count. That is not a statistic that sits comfortably next to a game sold as tennis without the strain. Among women, fractures were 71.7 per cent of their upper-limb injuries. Among men, 39.8 per cent. Put the two figures another way and the sex split is just as stark: 6,311 of those 8,747 fractures were in women, a little over 72 per cent of the fracture count. Healio’s short write-up slightly flattened this, leaving the impression that 71.7 per cent of all the injuries occurred in women. The paper is more precise, and more damning. Women did not merely show up more often. When they showed up, they were far more likely to have broken something.
This is an American dataset. NEISS samples American emergency departments and then weights the counts into a national estimate. There is no comparable UK series. What the American numbers still tell anyone who runs a club, a masters event or a senior professional bracket is that the growth story and the injury story are the same story, told from opposite ends of the court.
Participation, on the Sports and Fitness Industry Association figures the authors used, rose from 2.46 million players in 2014 to 8.95 million in 2022. The paper’s own results table puts the mean annual growth rate at 19.7 per cent. The abstract says 24 per cent, and Healio repeated the abstract. I am staying with the table. The same table is also clearer than the abstract about the year that 8.95 million belongs to: 2022, not 2023. The single wildest jump came in that year, when SFIA counted 4.13 million new players and a one-year growth rate of 85.7 per cent. The injury rate did not simply climb in a straight line underneath all that enthusiasm. Estimated upper-limb injuries per 100,000 participants went from 5.27 in 2015 to a peak of 62.74 in 2021, then fell back to 30.60 in 2022. That drop coincided with the great participation surge. More people in the denominator will do that to a rate. It does not mean the emergency rooms suddenly emptied.
The tennis comparison is the other useful argument in the paper, and it does not rescue anyone. Over the same period, tennis upper-limb injuries in the same surveillance system were more common in players under 60 (53.0 per cent) and in men (54.2 per cent). The shoulder still led in tennis, at 47.3 per cent, but fractures accounted for only 36.1 per cent of tennis upper-limb injuries, against 58.6 per cent in pickleball. Sprains and strains were more common in tennis (20.6 per cent) than in pickleball (11.1 per cent). Hospital admission followed 8.1 per cent of the pickleball upper-limb cases and 4.0 per cent of the tennis ones. Most of the pickleball injuries, 79.9 per cent, happened at a place of recreation or sport. Ninety per cent of patients were treated and released. The people who went home with a sling were still, overwhelmingly, older, and more often women.
Valdes and colleagues are careful, in the discussion, about why that fracture burden sits where it does. They point to falls as the leading mechanism, and to the familiar pattern of falling onto an outstretched hand that takes the shoulder girdle and the forearm with it. They cite the decline in bone density in older women, reduced upper-limb muscle mass, slower reaction times, and differences in protective reflexes. That is not a morality tale about people who should have stayed in the chair. It is a description of a sport that has spent a decade inviting those players in, often as beginners, onto a court that still asks for change of direction, stretched hands and sudden stops. The paper’s own introduction notes that during the 2021 growth spike, adults over 55 were the largest participation group. The emergency-department ledger is what that invitation looks like when it goes wrong.
There is a limit to what an emergency-department study can see, and the authors say so. Pickleball does not have its own NEISS product code. Cases were found under a catch-all ball-sports code, then pulled out by searching the narrative text for “pickleball” and the usual misspellings. The unweighted sample behind the national estimates is 250 upper-limb cases — 149 women, 101 men. That is a thin raw count for a decade of headlines, even once the weights have done their work. NEISS also misses everything that never reaches an emergency department: the urgent-care visit, the physio list, the player who plays through a sore shoulder for six months and never fills in a form. The rates themselves are participant-based, not exposure-based. SFIA can tell you how many people played in a year. It cannot tell you how many hours they played. A once-a-month beginner and a four-times-a-week regular count the same in the denominator.
That last gap is where a second body of work belongs in this piece, and it is not Valdes. In a perspective published alongside Healio’s summary, Wassim Mourad, of Saint Louis University School of Medicine, described a nationwide study by his group of 1,758 pickleball players in which nearly 69 per cent reported some form of pickleball-related physical complaint or injury in the previous year. Many of those, he noted, were non-time-loss or overuse injuries that traditional emergency-department surveillance would never catch. A subsequent study, focused on the upper limb, found that about 39 per cent of players reported an upper-extremity complaint, with the shoulder most often involved, then the elbow, wrist and hand or forearm, and with tendinopathies the most common type. I am taking those figures as Mourad stated them in Healio, not as numbers I have independently re-run. They matter because they describe the injury bill that never appears in an emergency department at all: the grind, not the snap.
The temptation, at this point, is to turn a column into a warm-up leaflet. The paper does offer prevention language — proper warm-up, suitable footwear, bone-health assessment, balance and strength work, rotator-cuff and forearm conditioning, even instruction on grip and technique — and it cites a 2025 training study by Myers and Hanks in which a ten-week programme of balance, strength and agility improved change-of-direction performance and reduced fear of falling. At five-month follow-up, 25 per cent of the training group reported falls during play, against 44 per cent in the control group. Those are useful findings. They are not a miracle cure, and they should not be sold as one. What they do support is a less fashionable claim: if clubs and tours are going to keep building senior calendars, they might also build the unglamorous work that keeps people on those calendars.
Look around the present calendar and the same argument is already on the fixture list. APP’s Arizona Open, which starts on Thursday in Mesa, is running full AARP Champions 50+ and Masters 60+ professional brackets. The Pan Pacific Masters Games has just put 301 players on court on the Gold Coast in divisions from 35+ to 80+. PPA Tour Europe’s French debut in Lille, by contrast, has no 50+ or 60+ professional event and a recreational 50+ men’s doubles bracket with one pair. The injury literature and the fixture list are having the same argument from different directions. Senior pickleball is no longer a novelty. The medical record is what happens when a sport grows old in public and still talks as if it were a garden game.
I do not read Valdes as a reason to scare women off the court. The social and mental-health benefits the authors themselves acknowledge are real, and so is the right of a 67-year-old to play a sport she enjoys. I read it as a reason to stop borrowing tennis’s injury assumptions, and to stop describing broken wrists as an unfortunate surprise. American emergency departments have been seeing this pattern for a decade. The people in the waiting room are, overwhelmingly, the players the sport congratulates itself for welcoming. If the next phase of growth is going to mean anything, the prevention work has to be aimed at them, not at a hypothetical young male athlete who was never the centre of this particular problem.
The bill is already on the table. It is written in fractures, and it has a demographic. Women over 60 did not invent pickleball’s injury problem. They have been carrying it.
