Pickleball is a unique sport that is sweeping the nation, borrowing aspects of squash, tennis and ping pong — to name a few. Anyone can learn how to play pickleball in a days time from an experienced player or coach. Regular play can build confidence, camaraderie, strength, endurance — not to mention FUN. 

Just like any sport, pickleball is not without risk of injury. Pickleball borrows footwork and paddle strokes from other sports, but pickleball requires repetitive lower/upper extremity movements that are not as prevalent in other paddle sports. These movements can lead to specific muscle strains. Players can prevent injury or treat it early on by learning how these muscle strains occur.

1. Groin Strains

In pickleball, a player is encouraged to maintain an athletic position (hips/knees flexed with feet wider than shoulders) at the Non-Volley Zone (NVZ). This athletic posture allows a player to perform dinks, blocks and overheads with good body control. It also allows the player to move medially or laterally without crossing one foot over another. In doubles, a player has to cover a minimum of 10 feet, and in singles it could potentially be 20 feet of court. By maintaining the athletic posture during long dink rallies or by moving laterally for an around the post shot, the groin muscles are prone to strains unlikely in other paddle sports. A strain is the medical term for a muscle tear. In this case, it is usually a hip adductor (groin) muscle that is involved.

2. Calf Strains

After the return of serve, players are encouraged to move up to the NVZ line while the serving team is advised to make their way to the NVZ as their third shot dictates. It only takes about six steps to make it to the kitchen line from the baseline, which doesn’t seem like a major athletic event. However, in a single eleven-point game lasting approximately 10 minutes, a player might have to move from the baseline to the kitchen line 40 to 50 times (15 feet each time), along with overhead lobs that may cause players to backpedal 10 to 15 feet. These movements make players prone to calf strains as they push off their forefoot to get to the ball.

3. Rotator Cuff Strain

Players at the baseline might decide to hit a ground stroke or a third shot drop, but if at the NVZ, a player has to be prepared for fast reflexive upper extremity movements. Your opponent is often only 14 feet away, and the ball can come at odd angles. If the ball is hit at chest level, then this shot requires a quick shoulder rotation to get in position. The shoulder can be put at a ninety-degree angle when trying to do an “Ernie,” a “Burt” or an around-the-post shot (APT) at the NVZ. The rapid nature of the shot at chest level can cause a quick stretch of the rotator cuff muscles that can lead to a muscle or tendon tear of the shoulder musculature.

PREVENTION

1. Strengthening

Most people who play sports several times per week will not make time for strengthening. Players should begin an extremity, core strengthening program two to three times per week. Weight training allows them to work specific muscles in pain free ranges. 

• Calf raises begin with 80 pounds for 2 x 15 repetitions with both lower extremities. 
• Dynamic exercises allow players to use body weight for resistance. 
• Wall push-ups for 2 x 15 repetitions with both upper extremities in pain free range. 

To build muscle. players must challenge the targeted area enough to cause fatigue but should recover within 48 hours. Building strong muscle systems allow players to accelerate and decelerate to get to the ball and hit it with confidence.

2. Stretching

It is good to perform active stretching before playing a sport. Active stretching involves elongating followed by contracting muscles that will be used during the activity to prepare for movement. For pickleball, players should engage the groin, calves and rotator cuff muscles to warm up. 

• The groin muscles will respond to lateral lunges or carioca. The groin can hold a lateral lunge position. 
• The calves can be stimulated with jumping jacks. For the calves, players can use the static forward lunge.
• The shoulders can be loosened up with arm circles first clockwise, then counterclockwise. Shoulder muscles stretch well with full overhead hangs or holding arms behind the back for 20 to 30 second holds.

Static stretches are better off done after playing as the muscles are already warm and the position can be held for 20 to 30 seconds for each extremity. 

3. Sports Drills

Drills are activities that break down sport movements that can be practiced safely to prepare for more complicated footwork or upper body work.

Groin muscles are stressed by doing lateral lunges across the service line from right to left for a certain number of reps, while calves can be stimulated by moving forward and backwards from the service line to the NVZ line at various speeds. 

For the upper body, players can hold the paddle and perform practice swings from forehand to backhand at various levels from waist to chest to overhead. 

These drills can help with strength, endurance, and coordination if practiced routinely.

4. Proper Technique/Strategy

By developing the most efficient footwork, ground strokes, volleys and overheads a player will have effortless control of the ball. As they develop power, placement and court positioning, the game will begin to slow down allowing a player to reduce muscle strains. By practicing a specific stroke, for example, cross court dinks players can work on our footwork and arm movements without worrying about the score or winning. 

Playing more often, being filmed, pickleball courses, individualized instruction from a professional or and watching instructional videos can help improve proper technique. 

TREATMENT FOR STRAINS

1. Grade 1 Strains

A grade 1 tear of a lower extremity muscle can occur as players push off the leg to reach for a ball or when rapidly slowing down to change directions. Either mechanism will cause tearing of muscle and/or tendon tissue in a local part of the lower extremity. Immediate pain can dissipate quickly by moving the involved tissue. For example, if a player feels a groin strain, he/she may perform several lateral lunges to relieve the pain. A loss of range of motion to the area between zero and 10 percent can occur with little loss of function. The pain will usually peak one to three days after the injury, and usually resolves within three weeks. Icing the injured area for 10 minutes a session can aide in pain and swelling relief in relation to the amount of tissue damage.

Treatments at this stage to help healing would include gentle motion, massage, bicycling, aqua exercise, walking, compression sleeve and gentle exercises e.g. mini squats and lateral lunges. People usually can return to pickleball without seeking medical assistance.

2. Grade 2 Strains

A grade 2 tear is like a grade 1 tear in that the mechanism for injury might be the same, but there is a 10 to 25 percent loss of motion, significant increase in pain and swelling and loss of function i.e., an antalgic gait (limp). The player will probably need help getting off the court because pain and swelling will be immediate. A visit to a primary care provider or orthopaedic provider would be recommended to find out the extent of the injury. The musculotendon injury will require some level of immobilization to help the healing process. For example, for a calf strain players might have to wear an ankle brace or a walking boot if more tissue is damaged.

Physical therapy is helpful to work on progressive therapeutic exercise, stretches, gait training and manual therapy, such as massage. Once normal function is achieved, sports drills can be added to the program. Full return to the pickleball court could take eight to 16 weeks depending on the location and amount of tissue tearing.

3. Grade 3 Strains 

A grade 3 strain is characterized by a 25 to 50 percent loss of motion or a complete rupture of muscle from its tendon or the tendon off the bone. This is a serious injury, and it will require a trip to the orthopaedist or the emergency department if the pain is unbearable. There will be a visible or palpable gap in the muscle or tendon area, and the player will not be able to move the distal part of the extremity. In the case of a grade 3 rotator cuff injury, the player would not be able to lift the shoulder above ninety degrees and would instinctively keep the involved arm against the trunk with the elbow flexed to ninety degrees to avoid any further shoulder movement. This is a medical emergency because it is important to seek repair before losing function of the area in the future. A shoulder injury will require a physical examination, followed by X-ray and magnetic resonance imaging (MRI) to rule out fractures and find what was torn.

Conservative treatment for Grade 3 tears would involve immobilization of the joint, medications and physical therapy. Once surgery is performed, physical therapy protocols will be recommended to ensure a safe return to full function. It might take a minimum of four to six months to get back on the pickleball court after a Grade 3 strain.

CONCLUSION

The words muscle strain may sound benign because anyone playing sports has probably had one. However, playing a new activity like pickleball can put some unique stresses on the body. Personally, I had a Grade 1 groin strain when I started playing singles pickleball two years ago. I had a Grade 2 calf strain last year running from the baseline into the kitchen to retrieve a dink, and a Grade 3 rotator cuff tear four months ago requiring surgery after my first successful Ernie shot. Hopefully, by learning about the specific stressors that pickleball places on the body, other players can train smarter, stretch more effectively and have better technique to avoid muscle related injuries to the lower or upper extremities.

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About Jay Goodman, PT, SCS

Jay Goodman is a long-time physical therapist and certified pickleball coach (as of August 31, 2022) who specializes in treating orthopedic issues and injuries related to sports and activity. He has worked with elementary, middle and high school athletes, college athletes and professional athletes throughout his long career. He also loves helping today’s office worker who suffers from “tech neck”, hip issues and other conditions related to sitting at a desk. Goodman received his bachelor’s degree in physical therapy from Hunter College in Manhattan and has much specialty training under his belt.

Goodman chose to go into physical therapy because he simply wanted to help people live better. As a physical therapist for almost 40 years, he has treated people ages 5 to 95 and watched their lives improve in meaningful and predictable ways with physical therapy. “When you help someone walk, run, swim or return to work again without pain, the rewards are priceless,” he says.

Specialty training: Temporal Mandibular Joint (TMJ) Therapy, Aquatic Therapy, Kinesio Taping, Manual Therapy, Strain-Counter-Strain Therapy, Sports Therapy & Training and Muscle Energy Technique