Common, usually settles, and pickleball is good for hipsEmerging evidence
A sore hip, groin or buttock after pickleball is common, and it usually settles. The NHS says "Hip pain is common, especially as you get older". 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), 14.2% reported a hip complaint over a year (women 15.5%, men 12.5%). That is one survey of players who chose to answer, mostly older and from the US, so it shows how often players notice their hips, not what causes it.
Pickleball is good for older hips and balance: 8 weeks of supervised pickleball moved 42% of pre-frail older adults to non-frail, against 8% of controls, and improved balance in older women by about 28% in a second small trial.
Sources 1, 2, 3, 4
Lunges, side steps and quick starts: tendons more than jointsEmerging evidence
At one US academic clinic, players with hip or thigh problems were the oldest group (average 66); two thirds had tendon problems (the hamstring at the sitting bone 22%, the iliopsoas hip flexor 22%, the outer hip tendons 11% and the iliotibial band 11%), and the authors write that "Tendinopathies in the thigh and hip may occur with sudden motion such as a lunge to reach the ball or run to the kitchen line". In emergency data, younger players' strains and sprains came more often from "sudden stops and lunging".
In tennis, a related sport, "Muscle strains are very typical for tennis and occur mainly in the adductor, hamstring, quadriceps, and gastrocnemius muscles", and in a lab study of 8 advanced tennis players a wide defensive open stance loaded the hip most, which the authors say "potentially" raises the risk of overuse injury (it wasn't measured).
Sources 5, 6, 7, 8
The outer hip: usually the gluteal tendons, not just a bursaStrong evidence
In 3,026 adults aged 50 to 79 living in the community, painful outer hip (greater trochanteric pain syndrome) affected one side in 15.0% of women and 6.6% of men, and both sides in 8.5% and 1.9%. On ultrasound, "Of the 877 patients with greater trochanteric pain, 700 (79.8%) did not have bursitis on ultrasound", and about half had gluteal tendon changes.
Tendons dislike being squeezed: "The combination of excessive compression and high tensile loads within tendons are thought to be most damaging". An NHS trust's leaflet says symptoms come "when lying on the painful side, during activities that require deep squatting, stair climbing or during and after impact exercise". In our reading, the long side steps, the lunges and a sudden jump in court time can add load, and so can standing on one leg with the hip dropped while you wait to play.
Sources 9, 10, 11, 12
The groin, the inner thigh and the front of the hipEmerging evidence
Groin pain in athletes is classed by the Doha agreement into "Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain". In pickleball, the side lunge and quick change of direction load the inner thigh muscles (the adductors) most, in our reading, and a pull at the front of the hip after lunging or sprinting to the net points to the hip flexors (iliopsoas), 2 of 9 hip and thigh patients at the US clinic.
A lump in the groin, especially one that appears when you cough or strain, is a possible hernia, not a strain, and the NHS hernia page says to see a GP about it.
Sources 13, 5, 14
Hip arthritis from mid-life: activity doesn't seem to wear out hips, though the studies partly conflictMixed evidence
The NHS says a GP may suspect osteoarthritis if "you're aged 45 or older", with joint pain that gets worse the more you use the joint and little morning stiffness. A flare of osteoarthritis was the commonest diagnosis among 545 pickleball patients in one health system (16%), mostly the knee, and "hip OA was the least common at 8%" of those flares (OA is osteoarthritis); arthritis-related pain was 10% of injuries at another.
On the evidence available, being active doesn't wear out healthy hips, but this rests on observational cohorts that partly conflict. In 28,320 Swedish adults, "leisure time physical activity showed no consistent overall relationship with incidence of severe knee or hip OA, defined as joint replacement due to OA, over 11 years", and in 5,911 people with hip arthritis, "High-impact PA was associated with 36-48% lower odds of THR" over a year (PA is physical activity, THR a total hip replacement). A Norwegian population study, though, found a possible link between high leisure activity and later hip replacement in some age groups, and former world-class athletes had about double the general population's risk, which doesn't apply to recreational play.
Sources 15, 16, 17, 18, 19, 20, 21
Falls: the serious hip injury to knowEmerging evidence
"Falls present one of the most serious injury risks in pickleball, particularly for ankles, knees, hips, and wrists", a Pickleball Queensland article says. In 92 recreational players, "Thirty-three percent of participants under the age of 55 reported a fall, whereas 61% of participants 55 years of age or older reported a fall", and "The two leading reasons for falls were lunging and moving backward".
In US emergency departments, falls caused 65.5% of pickleball injuries, and "The lower trunk (eg, hip and pelvis) was the most common injury site among admitted patients (42.2%)"; that code pools the hip, pelvis and lower back, so emergency data can't separate the back from the hip. Broken hips are reported only as small counts: pelvis fractures were 6 of 397 pickleball fractures over 21 years, one health system saw 11 hip or pelvic fractures among 487 pickleball patients, where in players over 60 "fractures (most commonly hip or wrist fractures) and arthritis-related pain became more common", and at one clinic 2 of 9 hip and thigh patients, both older women, had broken the neck of the thigh bone in a fall.
One review's authors write that "Pickleball injuries may be more severe among older players with osteoporosis or osteopenia, turning what might be a minor fall in a younger person into a fracture" (their opinion). That is a reason to build strength and balance, not to stop playing.
Sources 22, 23, 24, 25, 17, 5, 26
A catching pinch, and the buttockEmerging evidence
At the US clinic, tears of the labrum (the rim of cartilage round the hip socket) were seen on magnetic resonance imaging (MRI) scans in 2 of 9 hip and thigh patients. Tears are also common in hips that don't hurt: across imaging studies there was "a labral tear prevalence of 54% (95% CI 41% to 66%) in asymptomatic individuals".
A deep ache at the sitting bone, worse sitting, points to the hamstring tendon, 22% of the hip and thigh patients at the same clinic; buttock pain with back pain or pain down the leg points to the back, as our back pain from pickleball guide explains. A fall onto the bottom can bruise or, rarely, tear the buttock muscle: a 72-year-old player was back at pickleball about 4 weeks after a partial tear of the gluteus maximus treated without surgery.
Sources 5, 27, 28
When a scan or test mattersStrong evidence
After a fall with severe hip pain, or a leg you can't stand on, the NHS says "You'll usually be given painkillers and have an X-ray to check if your hip is broken". The National Institute for Health and Care Excellence (NICE) diagnoses osteoarthritis clinically, without imaging, in people 45 and over with typical symptoms. Outer hip pain is diagnosed by examination; the LEAP trial confirmed it with an MRI scan for research, but a scan isn't needed to start the exercise.
Scans of painful hips often show labral tears and cartilage changes that are just as common in hips that don't hurt, so a scan matters for a hip that catches, locks or gives way, for groin pain that hasn't settled after 6 weeks, or when surgery is being considered.
Sources 29, 30, 31, 27
How it usually goesEmerging evidence
Strains and aches settle in days to weeks. Outer hip tendon pain is slower: an NHS trust says "The rehabilitation process often takes months as tendons do not have a rich blood supply", and in the LEAP trial 31 of 60 people in the wait-and-see group reported success at a year, against 51 of 65 with education and exercise. Long-standing groin pain improved with 8 to 12 weeks of active training.
Hip arthritis comes and goes with flares, and exercise helps a little on average. After a hip replacement, pooled return to sport was 85%, at an average of 16.1 weeks, and 97% for low-intensity sports. No one can promise a date.
Sources 12, 31, 32, 33, 34
When it isn't pickleball: the causes the warning signs cover
Some hip pain has causes pickleball didn't create, and the warning signs follow the pages behind them. Severe hip pain after a fall, or a leg you can't stand on, can be a broken hip, a 999 call on the NHS hip pain and broken hip pages, and a fall where someone can't get up is a 999 call on the NHS falls page. The American Academy of Orthopaedic Surgeons (AAOS) says some people with a broken hip can still take part of their weight, which is why a fall with pain that makes walking hard needs checking the same day. Sciatica on both sides, or numbness around the genitals or bottom, is a 999 call in the NHS sciatica page's words.
A groin lump can be a hernia: the NHS hernia and femoral hernia pages say when it's an emergency, and NHS inform's hip problems page says to contact a GP for a lump in the groin or pain or swelling around the testicles. After a hip replacement, the NHS complications page lists the signs of a dislocation, a clot or an infection, and says when pain later on needs checking. Chest pain on court can be a heart attack or angina, and fainting while exercising needs a 999 call, as the NHS heart attack, angina and fainting pages say.
Bone pain that is worse at night is in the NHS bone cancer page's words, and a UK review in the BMJ says avascular necrosis (a loss of blood supply to the hip bone) can hide behind a normal X-ray early on. NHS inform's outer hip page says to talk to a healthcare professional if outer hip pain hasn't improved within 6 weeks. Two studies of athletes describe a complete tear of the adductor longus tendon in the inner thigh: a dent or gap you can feel, confirmed on MRI and treated with exercise in a small series. The Medicines and Healthcare products Regulatory Agency (MHRA) asks people on bisphosphonate bone medicines to report new thigh, hip or groin pain.
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 NICE's falls guideline, the NHS falls page and an Otago strength and balance booklet say a fall or near-fall needs a falls assessment. Buttock or leg pain on standing that eases with sitting is spinal stenosis, as a review of its clinical signs, a review in JAMA and South Tees Hospitals describe, and the NHS polymyalgia rheumatica page describes pain and stiffness in both shoulders and the hips, mostly over 50.
Sources 1, 29, 50, 51, 52, 14, 35, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73
