Common, usually settles, and serious injury is rareEmerging evidence
A sore lower back after a pickleball session, a week of extra games or a tournament is common, and it usually settles. The NHS says back pain "usually improves within a few weeks but can sometimes last longer or keep coming back", and that "Very rarely, back pain can be a sign of a serious problem such as a broken bone, cancer or an infection". In people with a new episode of low back pain, average pain fell from 52 to 23 out of 100 within 6 weeks.
Serious back injuries in pickleball are rare. In one analysis of US emergency departments, 88.0% of injured pickleball players were treated and sent home, and most visits followed falls. Spine fractures were 16 of 397 pickleball fractures seen over 21 years. In players aged 55 and over, the trunk's share of injuries was much the same in pickleball (17.5%) as in tennis (17.8%), and about half that in golf (34.6%). Emergency data can't separate the back from the hip, though: the US records group the lower back, hip and pelvis together.
Sources 1, 2, 3, 4, 5, 6
How often players notice their backs: mostly one survey of older playersEmerging evidence
In a self-selected online survey of 1,758 US recreational players who play at least monthly (average age 62.7, 56% aged 65 or over), "the back (19.9%)" was among the commonest places players reported pain, ache or stiffness over a year, behind the knee, the leg and foot and the shoulder, in men and women alike; 68.5% reported some pain, ache or stiffness somewhere. In 232 younger Korean tournament players (average age 50.5), "Trunk injuries were less frequent, including the lower back (6.0%) and upper back (4.3%)".
The back figure comes from one survey of players who chose to answer, mostly older and from the US, recalling a year, so it shows how often players notice their backs, not what causes it or how likely a new player is to get it. At one US health system, back pain or sciatica was the second commonest pickleball problem after the rotator cuff (48 of 618 injuries); across another, trunk or spine problems were only 4.4% of pickleball presentations.
Sources 7, 8, 9, 10
Bending low, twisting and lungingEmerging evidence
Pickleball is played close to the net with short steps, low dinks and drop shots, reaches across the body and balls picked up from the ground. One US clinic's authors write that "Low back pain may occur with repeated twisting motion of the spine", and younger players' strains and sprains in emergency data came more often from "sudden stops and lunging". No study has measured how much the back bends or turns in pickleball, or whether a different technique protects the back.
The Chartered Society of Physiotherapy (CSP) says back pain "can be disabling and worrying but it is very common and rarely dangerous", and on bending: "Bending and lifting are often portrayed as causes of back pain and while an injury can occur if something is picked up in an awkward or unaccustomed way, it’s most likely to just be a sprain or strain".
Sources 11, 12, 13
Playing more, and being newer to the gameEmerging evidence
In the US survey, playing more each week (odds ratio 1.45), fewer than 5 years' experience (1.50) and paying little attention to injury prevention (2.02) went with injury, while the authors note that "Neither increased duration of play nor higher body mass index significantly increased the odds of injury". In Korean tournament players, each extra weekly hour went with slightly higher odds. These are associations from surveys, not proof that playing more causes back pain.
Back pain is common in sport generally: across 86 studies of athletes, about half reported low back pain over a year, and "Risk factors for LBP included history of a previous episode with a pooled OR of 3.5" (LBP is low back pain; an odds ratio of 3.5 means a past episode made it much more likely).
Sources 7, 14, 15
Who gets hurt, and the other racket sportsEmerging evidence
Pickleball's injuries follow its players: in US emergency departments the average injured player was 64 and falls caused 65.5% of injuries, and over 85% of injured players in another analysis were 60 or over, where "Patterns of senior tennis and pickleball injuries were mostly similar". Men had higher odds of trunk injuries (odds ratio 1.28) and of strains and sprains, and women's injuries were more often fractures.
In related racket sports, back pain was no more common in 388 adult tennis players than in 245 people who didn't play ("None of the differences between tennis players and controls were significant."), while in recreational padel the lower back is among the commonest sore spots, behind the elbow, in some surveys.
Sources 4, 16, 17, 18, 19, 20
Pain down a leg, and spinal stenosisEmerging evidence
At one US specialist centre, "Among 1,527 pickleball-related orthopaedic injuries, 135 (8.8%) involved the spine (77% women, median age: 62 ± 12.4 years)"; most involved the lower back, the commonest complaint was nerve root pain down a leg (63%), and "Most patients sought outpatient care (98%) and 10% required surgical intervention, primarily spinal decompression". At another academic clinic, half of 10 spine patients had nerve root pain and half spinal stenosis, and "90% were managed conservatively with rest/PT and oral medications" (PT is physiotherapy). These are selected clinic patients, so the surgery rate is far higher than among all players.
Spinal stenosis, a narrowing around the nerves in the lower back, gives buttock or leg ache, heaviness or tingling on standing and walking. A South Tees Hospitals NHS trust page says "LSS affects about 11% of the general population but it is very uncommon under the age of 50" (LSS is lumbar spinal stenosis), and a review in JAMA describes "back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion". The American Academy of Orthopaedic Surgeons (AAOS): "People with spinal stenosis often feel better when they lean forward or sit down" and "Standing up straight or walking usually make the pain worse". In our reading, pickleball's bent-forward ready position may suit a stenosis back, while standing and walking between games may bring the leg ache on.
Sources 21, 11, 22, 23, 24
A fall onto the back or bottom, and thin bonesEmerging evidence
Falls cause most pickleball emergency visits, mostly from lunging and moving backwards. Spinal fractures are rare: trunk fractures (the pelvis, ribs and spine) were 43 of 397 pickleball fractures, 16 of them in the spine, and 92% of all the fractures followed falls.
In a review of warning signs, a spinal fracture was more likely with older age, long-term steroid tablets, a hard fall and a bruise or graze over the spine, and "Probability of spinal fracture was higher when multiple red flags were present". Sudden back pain after a minor fall from 50, or with long-term steroid tablets, needs a GP check, as the warning signs say.
Sources 25, 4, 5, 26
When a scan or test mattersStrong evidence
Most back pain after pickleball needs no scan. The National Institute for Health and Care Excellence (NICE) says "Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica". In 3,110 people without symptoms, "The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals", and the CSP says the rare serious causes that need a scan account for "just two per cent of cases".
A scan matters after a fall with pain in one spot over the spine (an X-ray first), with leg weakness or the cauda equina signs (an urgent magnetic resonance imaging, or MRI, scan in hospital), and for stenosis that is severe enough for surgery to be considered: South Tees says "For a group of people with severely limiting LSS, scans may be needed for surgical planning". With thin bones, a GP may offer a fracture risk assessment and a bone density scan.
Sources 27, 28, 13, 22
How it usually goesEmerging evidence
In 33 groups of 11,166 people with a new episode of low back pain, average pain fell from 52 out of 100 to 23 at 6 weeks, 12 at 26 weeks and 6 at a year; the CSP says most people "recover reasonably quickly, and many do so without treatment". Sciatica "usually gets better in a few weeks to a few months but can last longer", the NHS says.
Stenosis changes slowly: "Up to 60% of people with mild to moderate symptoms experience rapid improvement in symptoms or remain the same over time", and in people followed for up to 3 years without surgery, about a third improved, half stayed the same and 10% to 20% got worse. Back pain often comes back, and a previous episode is the strongest known risk factor in athletes, which is a reason to keep the strength work going once you're back on court. No one can promise a date.
Sources 2, 13, 29, 22, 23, 15
When it isn't pickleball: the causes the warning signs cover
Some back pain has causes pickleball didn't create, and the warning signs follow the pages behind them. Numbness around the genitals or bottom, new bladder or bowel trouble or both legs weak can be cauda equina syndrome, a 999 call in the words of the NHS back pain and sciatica pages. A fall where you can't get up is a 999 call on the NHS falls page, and severe hip pain after a fall can be a broken hip, as the NHS hip pain and broken hip pages say.
Chest pain that spreads to the arms, neck or jaw can be a heart attack, and chest tightness that comes with effort and eases with rest can be angina, as the NHS heart attack and angina pages say; the NHS fainting page gives the 999 sign for fainting while exercising, and its pulmonary embolism and deep vein thrombosis (DVT) pages the signs of a clot in the lungs. A burst abdominal aortic aneurysm (a swelling of the body's main artery) can cause sudden, severe tummy or back pain, a 999 call on the NHS aneurysm page; the NHS kidney infection, foot drop and septic arthritis pages, a Leicestershire NHS leg pain leaflet and NICE's guideline on cancer that has spread to the spine give the same-day signs.
Leg ache on standing and walking that eases with sitting or bending forward points to stenosis, as a review of the clinical signs in older adults with leg pain, the JAMA review and South Tees describe, and calf ache that goes after a few minutes' rest points to narrowed leg arteries, as the NHS peripheral arterial disease page says. The Royal Osteoporosis Society, the AAOS, the UK's National Osteoporosis Guideline Group (NOGG) and NICE describe fractures from thin bones after a minor fall, and an Essex NHS trust leaflet says that very occasionally a piece of broken bone presses on the nerves. The NHS sprains and strains page says when a strain needs a GP, its shingles page says the pain can come a few days before the rash, and NICE's spondyloarthritis guideline lists the features of inflammatory back pain.
Sources 1, 29, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 23, 22, 63, 64, 65, 66, 67, 68, 69, 70
