Video Analysis Comparing Pickleball and Tennis Gameplay: Is the Achilles Tendon At Risk?

Category: Sports; Ankle Introduction/Purpose: Pickleball is one of the fastest growing sports. In 2018, there were 3.1 million pickleball players in the U.S, a 12 percent increase from 2017. Individuals greater than the age of 50 or older accounted for 90.9% of pickleball injuries. Pickleball injuries were projected to cost the US healthcare system up to $500 million in 2023. Anecdotally, orthopaedic surgeons are noticing rising pickleball-related Achilles Tendon (AT) ruptures. However, there is a paucity of literature examining the incidence of Pickleball AT ruptures. Given the biomechanical similarities between pickleball and tennis, we compared the frequency of such at-risk movements for AT ruptures in these sports, hypothesizing that such movements would be greater in pickleball than in tennis match play. Methods: Publicly available footage of professional men’s and women’s singles matches from US Open Tennis and Pickleball Championships were collected and edited to display the first 5 minutes of active gameplay. Videos were then reviewed by 3 fellowship trained orthopaedic surgeons and 1 orthopaedic resident. Previous literature identified AT eccentric contractions, hip extension, knee flexion, and foot dorsiflexion leading to such ruptures. The authors determined at-risk movements (running takeoff/accelerating, pivot/cut) and body part positions, such as foot position (abduction, adduction, neutral, pronation, supination, dorsiflexion, plantarflexion), knee position in the sagittal plane, and hip position (extension, flexion). The number of at-risk AT movements was quantified and averaged among reviewers. Two-sided T-tests were used to evaluate for evidence of a statistically significant difference in the total number of at-risk ankle movements between the two sports. Results: After averaging across observations made by 3 orthopaedic surgeons and 1 orthopaedic surgeon resident, Pickleball players executed an average 97.59 (SD 8.08) at-risk movements and tennis players executed an average 68.39 (SD 10.75) at-risk movements per ankle with a significance value of 2.61E-07. When subdivided into individual ankles, there was still a statistically significant difference between the two sports (p< 0.001) with Pickleball having markedly more at-risk movements. This makes sense given that there was not a significant difference between Left and Right movements in either sport. Similarly, comparing ankle movements of each sport across and within each gender demonstrated a statistically significant difference as well (p< 0.05). Conclusion: In a small sample of professional athletes, there exists a significant increase in at-risk Achilles tendon movements of both ankles in Pickleball compared to Tennis independent of demographics. AT ruptures sustained during pickleball are multifactorial and the fraction of Achilles tendons that rupture during at-risk movements performed is exceedingly small. However, the higher frequency of at-risk movements during pickleball may influence pickleball-related AT ruptures. Being that pickleball has and will continue to grow in popularity, particularly with older age groups, evaluating the physical risks that this sport poses will help better inform athletic training and rehab programs for injury prevention.