Upper extremity pickleball injuries

While shoulder pain in pickleball players is often due to acute or overuse injuries, it’s crucial to consider underlying systemic or neurological conditions.

We’ve all seen the rapid growth of pickleball along with its increased injury rates, especially in the shoulders. This is due to repetitive overhead strokes and sudden movements. There are some issues to consider when seeing these injuries in your practice, especially in the aging population this sport attracts.

When a patient presents with upper extremity pain or injury and thinks it’s related to pickleball, you should typically consider a broad range of associated conditions beyond the immediate trauma. Consider the following potential issues:

Tendon inflammation and tears

Bursitis can cause pain and swelling, often linked with rotator cuff tendinitis.

Tendinitis/tendinopathy are often associated with inflammation, which is easy to pick up. I’ve seen enough ultrasounds and MRIs of the shoulder to know that by age 50, degeneration of the rotator cuff tendons is common in repetitive overhead activities.

Inflammation or degeneration of the biceps tendon contributes to anterior shoulder pain.

Rotator cuff tears can be partial, or a full-thickness tear can cause pain, weakness and limited motion.

Degeneration of the rotator cuff tendons is a gradual, age-related process that typically begins to appear in adults over the age of 40. Histological changes, such as collagen fiber disorientation and myxoid degeneration, are more frequently observed as age advances. In people under 20, rotator cuff abnormalities are rare (five to 10% prevalence). By age 40, tendon degeneration becomes more common, and the risk continues to increase with age. About 13% of those aged 50–59 have evidence of a rotator cuff tear, even if asymptomatic. By age 60–69, the prevalence rises to 20%. In the 70–79 age group, 31% have tears. For those over 80, more than half (51%) show rotator cuff tears. Studies consistently show degenerative tears are rarely seen before age 50, but the process of tendon degeneration starts earlier, often in the 40s.^1,2,3,4,5,6

• Instability and dislocations: Shoulder instability from ligament or muscle injury can cause recurrent subluxations or dislocations, leading to pain and functional impairment.
• Arthritis: Osteoarthritis is common, causing pain, stiffness and reduced range of motion. Other types, such as rheumatoid arthritis or posttraumatic arthritis can also affect the shoulder.
• Fractures: Breaks of the clavicle, humerus or scapula from trauma can cause severe pain and deformity.
• Impingement syndrome: Compression of rotator cuff tendons under the acromion causes pain with overhead activities.
• Adhesive capsulitis (frozen shoulder): This condition is characterized by stiffness and loss of motion due to thickening and contracture of the joint capsule.
• Labral tears: Injury to the cartilage rim of the shoulder socket causes pain, catching or instability.
• Nerve-related issues: These include brachial plexus injury or nerve impingement, which can cause shoulder pain and neurological symptoms.
• Bone pathologies: Issues involving bone include tumors, avascular necrosis (bone tissue death) and Paget’s disease, a disorder involving abnormal bone formation and resorption
• Pain syndromes: Fibromyalgia or complex regional pain syndrome (shoulder-hand syndrome) need to be considered. Cervical spine disorders or other systemic diseases may also present as shoulder pain.
• Heart disease: With shoulder issues, we must think about mild symptoms or early warning signs of heart disease; these can include mild angina (intermittent chest pain), fatigue, shortness of breath, palpitations, mild swelling, dizziness and mild chest discomfort (e.g., heart attack).

Systemic and neurological indicators

While most shoulder pain in pickleball players stems from acute or overuse injuries, you should always consider possible systemic or neurological conditions. My recommendation is to start by asking yourself, “Could this shoulder pain be a window into a larger systemic or neurological issue?”^7,8,9,10

Beyond the rotator cuff and other musculoskeletal injuries, here are a few obvious systemic and neurological indicators:

• Parkinson’s disease: In PD, shoulder pain/stiffness precedes motor symptoms such as tremor or bradykinesia, generalized slow movement, sometimes by years. Frozen shoulder (adhesive capsulitis) occurs in about 46% of PD patients, often bilaterally. Supraspinatus tendon thickening or tears observable on imaging do occur. The takeaway is one of the first signs of Parkinson’s disease could be a subtle one such as shoulder pain, loss of arm swing or a digestive disorder.
• Brachial plexopathy (Parsonage-Turner Syndrome): Sudden, severe unilateral shoulder pain followed by weakness/atrophy. No trauma history; often misdiagnosed as cervical radiculopathy. MRI may show brachial plexus inflammation.
• Ankylosing spondylitis: Inflammatory shoulder pain with morning stiffness that lasts more than 30 minutes; enthesitis (e.g., of the Achilles tendon) or sacroiliac joint pain; a positive HLA-B27 test; imaging that shows bone marrow edema/synovitis.
• Referred pain: Could be cardiac ischemia (left shoulder pain), cervical radiculopathy or gallbladder disease.^11,12,13

The examination: Here’s what to look for

• History: Onset (sudden vs. gradual), trauma, occupational/repetitive motions
• Systemic symptoms: Morning stiffness, fever, weight loss, cardiac/gastrointestinal issues
• Neurological symptoms: Weakness, numbness, radiating pain
• PD screening: Resting tremor, rigidity, bradykinesia
• AS screening: Sacroiliac joint tenderness, limited spinal mobility
• Brachial plexopathy: Sensory deficits, muscle atrophy
• Visual: Checklist for history/exam with emphasis on red flags

Imaging/labs if suspecting:

• PD: Brain MRI (to rule out other causes), DaTscan
• AS: HLA-B27 testing, sacroiliac joint X-ray/MRI
• Brachial plexopathy: EMG/NCS, brachial plexus MRI
• Referral indicators: Unexplained bilateral shoulder stiffness (PD). Inflammatory markers/enthesitis (AS). Sudden weakness without trauma (Parsonage-Turner).

Final thoughts on pickleball related injuries

Although shoulder pain in pickleball players is commonly linked to acute or repetitive strain injury, don’t overlook the possibility of deeper systemic or neurological causes, due to the typical age range of patients who play this sport. Conditions such as Parkinson’s disease, Parsonage-Turner Syndrome and ankylosing spondylitis, can manifest through shoulder symptoms long before more classically recognizable signs appear. By investigating whether the pain could be a sign of a broader health issue, you can promote earlier diagnosis and more effective treatment strategies.

Jeffrey Tucker, DC, is in private practice in Los Angeles, California. For more information, visit drjeffreytucker.com.

Editor’s note: Look for Part 2 of Tucker’s article in an upcoming issue of Chiropractic Economics, where he will explain the use of TECAR therapy for pickleball injury treatment and prevention.

References

1. Varacallo MA, et al. Rotator cuff syndrome. March 2024. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK531506/ . Accessed August 29, 2025.

2. Tempelhof S, et al. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296-299. https://pubmed.ncbi.nlm.nih.gov/10471998/ . Accessed August 29, 2025.

3. Zumstein MA, et al. Rotator cuff pathology: State of the art. Journal of ISAKOS. 2017;2(4):213-221. https://www.sciencedirect.com/science/article/pii/S2059775421002443. Accessed August 29, 2025.

4. Keener JD, et al. Degenerative rotator cuff tears: Refining surgical indications based on natural history data. J Am Acad Orthop Surg. 2019;27(5):156-165. https://pmc.ncbi.nlm.nih.gov/articles/PMC6389433/. Accessed August 29, 2025.

5. Ichinose T, et al. Factors affecting the onset and progression of rotator cuff tears in the general population. Scientific Reports. 2021;11(1858). https://www.nature.com/articles/s41598-020-79867-x. Accessed August 29, 2025.

6. Hsu J, Keener JD. Natural history of rotator cuff disease and implications on management. Oper Tech Orthop. 2015;25(1):2-9. https://pmc.ncbi.nlm.nih.gov/articles/PMC4695395/. Accessed August 29, 2025.

7. Ho J, Aibinder WR. Shoulder pain and common shoulder problems. January 2024. [Article]. American Academy of Orhtopaedic Surgeons. https://orthoinfo.aaos.org/en/diseases–conditions/shoulder-pain-and-common-shoulder-problems/. Accessed August 29, 2025.

8. Linaker CH, Walker-Bone K. Shoulder disorders and occupation. Best Pract Res Clin Rheumatol. 2015;29(3):405-423. https://pmc.ncbi.nlm.nih.gov/articles/PMC4836557/ . Accessed August 29, 2025.

9. Shoulder pain symptoms. Mayo Clinic. https://www.mayoclinic.org/symptoms/shoulder-pain/basics/causes/sym-20050696. Accessed August 29, 2025.

10. Paggou D, et al. Shoulder dysfunction in Parkinson Disease: Review of clinical, imaging findings and contributing factors. J Musculoskelet Neuronal Interact.2023;23(2):263-280. https://pmc.ncbi.nlm.nih.gov/articles/PMC10233223/. Accessed August 29, 2025.\

11. Tee-Melegrito RA. What to know about ankylosing spondylitis and shoulder pain. Medical News Today. July 2023. [Blog]. https://www.medicalnewstoday.com/articles/ankylosing-spondylitis-and-shoulder-pain. Accessed August 29, 2025.

12. Whelton R. Shoulder pain: Causation, differential diagnosis, and physical therapy. Pract Pain Manag. 2022;22(6). https://www.medcentral.com/pain/shoulder/shoulder-pain-causation-differential-diagnosis-and-physical-therapy. Accessed August 29, 2025.

13. Pain in Parkinson’s Disease. [Fact sheet]. Parkinson’s Foundation. https://www.parkinson.org/library/fact-sheets/pain. Accessed August 29, 2025.