Pickleball is the fastest-growing sport in America, and the clinical evidence on what it's doing to feet and ankles is finally catching up. The Sports & Fitness Industry Association reported that 19.8 million Americans played pickleball in 2024 — a 45.8% jump in a single year, and the Association of Pickleball Professionals' broader methodology puts the figure as high as 48 million when casual players are included. Whichever number you trust, one fact is uncontested: pickleball pulled millions of mostly older, mostly recreational athletes onto a court for the first time, and their feet were not ready.

The injury data is now unambiguous. A 10-year analysis of national emergency department records found that pickleball-related ED visits rose from 1,313 in 2014 to 24,461 in 2023. A separate study tracking the 2020-2022 window alone documented a 91% increase in injury-related ED visits and a 257% increase in hospitalizations. And when researchers isolated lower-extremity injuries, they found a 6.5-fold rise in pickleball foot-and-ankle injuries from 2019 to 2023. That's not a sport finding its level. That's a public-health pattern.

The dominant wrong belief: "It's just a low-impact game"

Walk past any community court and you'll hear some version of it. Pickleball is easier on the body than tennis. The court is smaller. The points are shorter. My doctor told me to play it because it's gentle.

It is true that pickleball covers less ground than tennis, has fewer overhead serves, and uses a slower ball. It is also true — and the clinical record makes this plain — that those features are exactly what makes pickleball hazardous to a deconditioned foot. Smaller court means more direction changes per minute. Shorter points mean more starts and stops. The slower ball means longer rallies — more cumulative repetitions of the same lateral cut, forward lunge, and explosive push off the heel.

The Kingston et al. study published in Foot & Ankle International in 2024 quantified this directly. Of the 198 patients diagnosed with pickleball-related foot or ankle injuries, the mean age was 58.3, the majority were male, and the most common mechanism reported was running or lunging forward (29.7%), followed by foot or ankle inversion (14.8%) and moving backward (8.0%). The most common diagnoses were Achilles tendon rupture (39.4%), gastrocnemius injury (16%), and Achilles tendinopathy (12.1%).

That's the calling card of an underprepared posterior chain meeting a sport that demands eccentric calf loading on every changeover. "Low-impact" is not the same as "low-stress on the foot and Achilles." Pickleball is, mechanically, a high-cycle, deceleration-heavy sport. The smaller scale concentrates the load rather than reducing it.

What 48 million new players are getting wrong

The clinical literature on pickleball injury is young, but the patterns are consistent across the studies cited above. Here are the five things showing up over and over in the patient histories.

1. Wearing running shoes on the court

This is the single most common — and single most fixable — mistake in the sport. Running shoes are engineered for one thing: a repeated heel-to-toe roll forward. The midsole is intentionally curved to encourage forward propulsion. The upper is built light and flexible because runners don't need lateral containment. The outsole has minimal lateral coverage because runners aren't supposed to go sideways.

Pickleball is the opposite. It is a side-to-side sport with sharp lateral cuts, abrupt stops, and unpredictable direction changes. A running shoe in this environment behaves the way it's designed to — it rolls forward when you don't want it to, deforms laterally because the sidewall isn't reinforced, and rotates the foot inward when you plant. That's the inversion mechanism that produced 14.8% of the foot-and-ankle injuries in the Kingston dataset.

Court shoes — tennis, indoor volleyball, dedicated pickleball — are built differently. The sidewalls are reinforced, the platform is wider, the outsole wraps further up the side of the foot, and the midsole is flatter to keep your center of gravity stable during lateral cuts. They are not interchangeable with running shoes, and the difference is not marketing.

2. Skipping the warm-up because "it's just pickleball"

The Achilles tendon is one of the most loaded tissues in the human body, and its tolerance for sudden eccentric loading drops sharply with age. By 50, the collagen turnover in the Achilles slows, the tendon becomes stiffer and less elastic, and the calf complex doesn't generate the same shock absorption it did at 30. This is not a pickleball problem — it's a biology problem. Pickleball just exposes it.

The clinical pattern in the Kingston paper is consistent: middle-aged or older players, no warm-up, sudden forward lunge or push-off, immediate Achilles rupture or gastrocnemius tear. A separate 2026 review of Achilles injuries in older pickleball players reached the same conclusion: the rising incidence is being driven by older recreational adults loading a tendon that hasn't been progressively prepared.

Five minutes of dynamic warm-up — leg swings, walking lunges, calf raises, easy lateral shuffles — meaningfully reduces the eccentric stress shock to the Achilles when play begins. Skipping it does not save time; it borrows from the tendon at compound interest.

3. Playing five days a week with no progression schedule

Recreational athletes who pick up pickleball tend to do one of two things: dabble in it for a month and quit, or fall in love and play four to six days a week immediately. The second group accounts for a disproportionate share of overuse injuries.

The principle here is the same one running medicine has been preaching for decades. Tissue adaptation lags behind cardiovascular adaptation. You can be fit enough to play three hours a day within a month of starting; your plantar fascia, Achilles, and intrinsic foot muscles need substantially longer than that to remodel under the new load. The injury isn't the activity — it's the rate of escalation.

A reasonable on-ramp for a previously sedentary 55-year-old: two play sessions a week for the first month, three for the second, four if and only if you're symptom-free. Treat the foot like a runner treats mileage — don't increase weekly volume by more than roughly 10% from one week to the next, and back off if anything new starts hurting.

4. Ignoring the morning heel pain until it becomes a problem

The single most common overuse pattern in pickleball that doesn't show up in the ED data — because it never gets to the ED — is plantar fasciitis. The repeated forward lunge to a low ball, the explosive push off the toes during a kitchen exchange, the cumulative hours of standing on a hard court surface: these load the plantar fascia in exactly the way the tissue is most vulnerable to.

The first sign is almost always a sharp, stabbing pain in the heel during the first few steps in the morning, or after sitting for an extended period. It eases as you warm up and you tell yourself it's nothing. Two months later, it doesn't ease. Six months later, you can't walk the dog without limping.

The clinical evidence on plantar fasciitis is well-established and applies cleanly to recreational pickleball players. Landorf et al. 2006 demonstrated in a randomized trial that prefabricated foot orthoses produced clinically meaningful pain reduction in plantar fasciitis patients, and the broader Cochrane evidence (Hawke et al. 2008) showed that quality prefab inserts performed comparably to expensive custom orthotics for the majority of patients. The point is not that orthotic support cures plantar fasciitis. The point is that load redistribution — taking tension off the inflamed insertion at the heel — is the mechanical intervention with the strongest evidence base, and one of the cheapest.

5. Buying "cushioned" inserts instead of structured ones

This is the second most common footwear mistake after wearing running shoes, and the two often compound. A player feels foot pain, walks into a pharmacy, and buys the squishiest gel insert on the shelf. It feels great in the store and does almost nothing on the court.

The mechanical problem in pickleball foot pain is rarely a lack of cushioning. It is a lack of structural control — the foot collapsing inward as it loads, the arch flattening under repeated lateral cuts, the heel translating in a shoe that doesn't hold it. A cushioned insert addresses none of these. A structured insert with a rigid shell, a deep heel cup, and a supported arch does.

The 2023 JOSPT clinical practice guideline on plantar fasciitis (JOSPT 2023) lists prefabricated foot orthoses among the strongly recommended early interventions, specifically because of their ability to redistribute load away from the inflamed plantar fascia. Cushioning is rated lower precisely because it doesn't address the underlying mechanical issue. The thumb test is the easiest way to tell the difference: press hard on the arch of the insert. If it flexes meaningfully, it isn't doing the job.

What actually works: the four-part protocol

If you've read this far, you're either already injured or you'd like to avoid being on the wrong side of the next epidemiological study. Here is the simplest evidence-based protocol that handles both cases.

1. Switch to a court shoe. Tennis or pickleball-specific. Reinforced sidewalls, wider platform, flatter midsole. This is non-negotiable if you play more than once a week. Expect to spend $80-$140; the cost-of-injury math makes it the cheapest intervention in the sport.

2. Build the calf back up. Two to three times a week, do progressive heel raises — both standard and eccentric (slow descents). Start with bodyweight, two sets of fifteen, both legs. Progress to single-leg raises, then to weighted, then to slow eccentric drops off a step. The Alfredson eccentric protocol has decades of evidence behind it for both prevention and rehabilitation of Achilles tendinopathy. Four minutes a day.

3. Add structural foot support. If you have any history of plantar fasciitis, flat feet, overpronation, or recurring foot pain, a structured prefab insert in your court shoe is the highest-leverage intervention you can make. Look for a polypropylene or rigid-shell base, a deep heel cup of at least 15mm, and arch support that doesn't flatten under thumb pressure. Skip anything labeled "memory foam" or "gel."

4. Warm up. Every time. Five minutes is enough. Walking lunges, leg swings forward and laterally, calf raises, some easy diagonal shuffles. The Kingston injury data is essentially a catalogue of cold-tissue ruptures. The intervention is not exotic.

If you're already hurting

If you have heel pain that's lasted more than two weeks, calf or Achilles pain that is sharp rather than achy, or any sudden "popping" sensation followed by pain or weakness — stop playing and see a clinician. Achilles ruptures are time-sensitive. Plantar fasciitis treated early resolves in weeks; treated late, it can take a year or more to fully resolve.

For early-stage plantar fasciitis or general overuse foot pain that hasn't crossed into structural injury territory, the home protocol is straightforward: load reduction (cut play volume by half for two weeks), targeted calf and intrinsic foot strengthening, plantar fascia and gastrocnemius stretching morning and evening, and structured orthotic support to redistribute load away from the inflamed tissue. Most recreational players return to full play within four to eight weeks if they're disciplined about it.

Pickleball is going to keep growing. The clinical literature on its injury patterns is going to keep growing with it. The encouraging part is that almost everything driving the foot-and-ankle surge is preventable with footwear, conditioning, progression, and structural support — none of which require a clinic visit, a prescription, or a $450 custom orthotic. The court isn't the problem. Showing up to it unprepared is.

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