As pickleball’s popularity has skyrocketed, so have the number of serious injuries among players.

Bone fractures related to pickleball have increased 200% over the last 20 years, according to an analysis of a large government injury database presented at the annual meeting of the American Academy of Orthopaedic Surgeons on Monday.

Pickleball, which is played with a perforated plastic ball and wooden paddles on a badminton-sized court, is the fastest growing sport in the U.S., with the number of players rising from 4.8 million in 2021 to 8.9 million in 2023, according to USA Pickleball.

What are the most common pickleball injuries?

The overall rate of injuries is likely much higher. The new analysis only looked at fractures, not the most common soft tissue injuries like sprained ankles or debilitating knee injuries such as damage to the ACL, or anterior cruciate ligament. Other common pickleball injuries include rotator cuff injuries, worsening of arthritis, Achilles tendon tears/strains and foot fractures.

The vast majority of the fractures found in the new study, 92%, occurred during falls.

“While pickleball is a great sport, nothing is without risk,” said the study’s lead author, Yasmine Ghattas, who is in her last year of medical school at the University of Central Florida College of Medicine in Orlando.

The researchers aren’t arguing for people to quit playing pickleball, just to be better prepared. “Well informed participation in any activity is key,” she said.

Ghattas had a personal interest in the topic.

“My fiancé and I play pickleball regularly and are both entering the orthopedic field,” she said. “During our clinical rotations, we noticed more and more patients coming in with pickleball-related fractures, so we looked to see if there were any studies and there weren’t, so we decided to take a deeper dive.”

The database the researchers used to explore the topic, the Consumer Product Safety Commission’s National Electronic Injury Surveillance System, contained a representative sample of injuries gathered from 100 U.S. emergency departments. Ghattas and her colleagues found descriptions of 377 pickleball-related fractures in the database between 2002 and 2022, which, when extrapolated to the entire U.S. population, totaled to approximately 5,400 pickleball-related fractures annually.

Women, especially those ages 65 and older, were more likely than men to experience a fracture. Most of those fractures were in upper-body bones, such as those in the forearms and hands. The researchers suspect they were related to osteoporosis or other bone-thinning conditions.

Even though women had more fractures overall, men were 2.3 times more likely to be admitted to the hospital after breaking a bone. Ghattas and her colleagues suspect that’s because men’s fractures tended to be in bones of the lower body, such as the hip and femur, which are more likely to result in a hospital stay than fractures in the upper body.

While the rise in injuries may mostly be tied to the growth of the sport, other factors may be coming into play, said Dr. Eric Bowman, an assistant professor of orthopedic surgery at Vanderbilt University Medical Center.

For example, some of the people taking up the sport may not have learned enough about it in advance, said Bowman, who was not involved in the study.

“It’s not enough to just pick up a paddle and get out there,” he said. “As with any sport, you have to learn the mechanics and the form that leads to better performance and injury prevention. Some people may not have learned enough, or be physically prepared in advance.”

A study co-authored by Bowman that has not yet been published finds that between 2017 and 2022, the incidence of pickleball-related injuries rose faster than the growth of the sport’s popularity.

Bowman’s study found that soft tissue injuries were the most common overall. Fractures and a worsening of arthritis were increasingly found in patients 60 and older.

While a sport like pickleball might be good for the cardiovascular system, the study shows that people need to be careful about how they begin, said Dr. Spencer Stein, an assistant professor of orthopedic surgery in the division of sports medicine at NYU Langone Health in New York City.

 “You want to be careful any time you enter a new sport,” Stein said. “You should get checked by your primary care doctor and get screened for osteoporosis or thinning bones.”

It’s also important that you warm up before playing and choose the right shoes for the sport, Stein said. And you should learn a very important skill: falling in a way that’s unlikely to lead to injury, he said. “If you fall more towards your side, you can protect your head but not putting your wrists at risk,” he added.

People tend to think of pickleball as relatively safe because it’s a lower-impact sport than tennis, for example, Stein said. But even so, competitiveness may lead people to overdo it.

Stein notes that middle-aged women may already be losing bone, which puts them at risk for fractures. That’s why it’s important to get a bone scan, he said. “Typically people start getting those scans at 65, but if there’s a family history of fractures it makes sense to start earlier, even as young as age 50,” he added.