Colorado ranks Number 6 in the US for increased participation in the sport of pickleball. Given Colorado’s large fitness oriented population, it is no surprise Colorado ranks high in the national surge of this sport. There has been a whopping 39.3% increase in pickleball players in Colorado over the past two years.

Unfortunately, injuries do occur in this sport. Richard Cunningham, MD, a Board Certified Orthopedic Surgeon and Sports Medicine Knee and Shoulder Specialist, wants to educate you on the most common pickleball injuries.

Knee Injuries in Pickleball Players

Pickleball players place considerable demand on their knee joint. Although less than tennis, there is still some degree of cutting and pivoting. This in combination with the impacts associated with the hard playing surface can cause knee injuries. The top three knee injuries seen in pickleball players include:

General Knee Pain and Arthritis Aggravation – Most people playing pickleball in Colorado are older and have some pre-existing knee arthritis. You may flare up this arthritis while cutting and pivoting on the pickleball court and notice the following symptoms:

• Stiffness and tightness of the knee, especially in the morning
• Stiffness that improves with knee range of motion
• Pain in the knee
• Swelling and warmth of the knee
• Tenderness to the touch
• Reduced knee range of motion

These knee symptoms can be treated with:

• Rest, ice, compression and elevation (RICE) of the knee
• Activity modification to allow pain and swelling to reduce
• Anti-inflammatory medications
• Physical therapy

With these treatments, players can often return to play relatively soon.

For patients with chronic knee pain or known osteoarthritis of the knee, a more intensive treatment plan may be required. Extended rest from play may be needed. Injections with either corticosteroid or hyaluronic acid may get you out of a bad flare of osteoarthritis. Formal physical therapy may be helpful. If symptoms persist despite these treatments, evaluation by an orthopedic sports medicine specialist is indicated to determine if there is a meniscus tear or loose body in the knee joint. Dr. Cunningham, an experienced knee specialist, has a wealth of experience treating persistent knee pain and can provide a comprehensive diagnosis and treatment plan.

Knee Strain and Sprain – Pickleball players rely on quick, forceful movements of the knee joint that can result in knee strains and sprains. Hamstring, patellar tendon, and quadriceps tendon strains occur. These tendon injuries range from tendonitis to tendon tearing. These symptoms vary from mild to severe:

• Localized pain over the involved tendon
• Tender and warmth to the touch
• Bruising
• Swelling and stiffness
• Popping sound at the moment of injury
• Loss of stability with walking

Dr. Cunningham will get a history of how the injury occurred and then do a focused physical exam of your knee to help determine the diagnosis. An MRI may be required. Treatments are most often nonsurgical and consist of the measures mentioned above. Mild to moderate tendon strains can take approximately 6 weeks to heal. Tendon tears may require surgical repair and if so, the recovery can take 4-6 months to heal.

Although less frequently, knee ligament tears do occur in pickleball. The most common ligament tears are those to the MCL and/or ACL. Dr. Cunningham has extensive expertise in the treatment of knee ligament injury. See this link for in depth information on a typical knee ligament treatment approach.

Dr. Cunningham, a specialized knee doctor, is available to consult with patients about pickleball knee injury prevention, diagnosis, and treatment.

Shoulder Injuries in Pickleball Players

Pickleball players place significant demands on their shoulder. Dr. Cunningham, a shoulder specialist, outlines the top three shoulder injuries seen in pickleball players:

Shoulder Impingement – The shoulder is a ball and socket joint. However, unlike the hip joint the socket is very shallow which allows for a fuller range of motion while also predisposing to other injuries. Persistent overhead motion can stress the shoulder complex and result in impingement. Impingement is an irritation and inflammation of the rotator cuff tendon on the top of the shoulder (supraspinatus) and its overlying bursa sac as a result of the tendon rubbing up against the acromion bone above it. This condition is also referred to as rotator cuff tendonitis or subacromial bursitis. Patients often localize the pain over the side of the shoulder in the region of the deltoid muscle. They may complain of popping as well as pain when reaching overhead or behind such as when putting on a coat. Bone spurs off of the acromion can predispose to this condition.

Pickleball players may notice these symptoms:

• Awakening from sleep due to shoulder pain particularly if you lie on the affected shoulder
• Shoulder weakness
• Pain with certain motions, especially overhead
• Pain relief from taking anti-inflammatory medications and from using ice

Physical therapy often combined with a steroid injection are usually effective in treating shoulder impingement. Surgery is not usually required.s If conservative home care, including RICE, combined with inflammation and pain management does not reduce symptoms, or the condition worsens, the shoulder should be evaluated to be sure that you don’t have a rotator cuff tear. Dr. Cunningham offers comprehensive shoulder evaluation and treatment.

Rotator Cuff Pain – For pickleball enthusiasts, it is not just overhead motions, but outstretched arm motions that can cause discomfort. The repetition of these motions can cause rotator cuff pain. Shoulder weakness, dull achiness, and sleep disruption are common signs of a rotator cuff tendon tear.

The shoulder complex is supported by four small muscles and their associated tendons that comprise the rotator cuff. Each muscle originates from the scapula (shoulder blade) and its associated tendon attaches to the top of the humerus (upper arm). Together the four muscles work in conjunction to power the shoulder in forward flexion, abduction, external, and internal rotation.

It is easy to see how the demands of pickleball can impact these muscle tendon units. The amount of repetition and force in the game can result in rotator cuff pain. Injury may range from:

• Muscle strain – micro tears to the muscle
• Tendonitis – inflammation of the rotator cuff tendons
• Bursitis – inflammation to the bursa sac that overlies the rotator cuff tendons
• Rotator cuff tendon tear where the tendon pulls off its attachment on the humerus

Dr. Cunningham’s treatment begins with a thorough history to understand how you injured the shoulder, where the pain is located, and what activities worsen the pain. He then does a directed physical examination of the shoulder and assess for weakness in each of the four rotator cuff muscles and to rule out other shoulder conditions. If a patient does not have evidence of rotator cuff weakness and if your shoulder pain is consistent with rotator cuff tendonitis, specific physical therapy will be prescribed. He may also perform a steroid injection to calm down the inflammation in the bursa and tendon in order to provide pain relief and allow for better sleep. Otherwise, overhead sports are temporarily discontinued. Anti-inflammatory pain medication and ice can help alleviate pain. Light rotator cuff stretching and strengthening exercises can be slowly introduced.

Rotator Cuff Tear – Pickleball athletes may experience a tear of the rotator cuff. Normal wear and tear over time predisposes the tendon to tear with overhead sports. A fall on an outstretched arm can also cause a tear. However, there is usually not one specific injury which causes a rotator cuff tear. As Dr. Cunningham says, “the rotator cuff is like a fan belt in your car engine. You only get so many miles until one day it just tears.” Symptoms include:

• Weakness of the shoulder
• Referred pain down the side and/or front of the shoulder
• Pain, especially with certain motions such as reaching overhead or behind
• Sleep disruption
• Popping and cracking noises during shoulder movement

If you have these symptoms, you should seek evaluation by an orthopedic shoulder specialist. You don’t want to miss a rotator cuff tear as the tendon can start to pull away or retract from its normal insertion over time making a potential repair more challenging. A patient history, physical examination of the shoulder, xray, and an MRI of the shoulder will establish the correct diagnosis. A rotator cuff tear is graded by its size and by how many of the 4 rotator cuff tendons are involved.

If there is a full rotator cuff tendon tear and you are an active person with ongoing pain and weakness, you are best treated with a rotator cuff repair surgery. Dr. Cunningham has done thousands of these surgeries. He does them arthroscopically through tiny incisions so the surgery is less invasive and less painful. In surgery, the torn and often retracted tendons are freed up from scar tissues and then mobilized and secured back to their normal attachment sites on the top of the humerus bone using small non-metallic suture anchors. The torn tendons are sewn back onto bone that is abraded so stem cells are oozing from the bone, which helps the tendons heal. After surgery, patients have to wear a sling for 6-8 weeks depending on the size of the tear, and physical therapy is slowly progressed so as not to stress the repair. It can take 4-6 months to be able to return to demanding overhead sports such as pickleball, but activities such as stationary biking and walking can be started right after surgery. Dr. Cunningham, a shoulder specialist, provides rotator cuff tear patients with the optimal surgical procedures so that they are able to return to pickleball and all preferred activities as quickly as possible.

Dr. Cunningham, a sports medicine shoulder and knee specialist, and his expert care team can keep you in the game. Contact his Vail, CO office at (970) 476-2451, Edwards, CO office at 970-569-3240, or his Frisco, CO office at (970) 668-3633.