What every pickleball player needs to know about the shoulder — before it starts screaming at you.
PATIENT STORY
“I just play recreational pickleball a few times a week. It cannot be that serious, right? — A very common sentence I hear in my office, usually followed by an MRI that tells a very different story.”
*Composite patient story. No identifying information used.
Pickleball has officially taken over. From San Antonio community centers to retirement communities to competitive leagues, the sport has exploded in popularity — and for good reason. It is fun, social, easy to learn and a great way to stay active. As someone who believes deeply in movement, wellness and longevity, I absolutely love that millions of people have found a sport they enjoy.
But here is the thing I need to tell you as your surgeon: pickleball is not as low-impact as it looks. That overhand serve, that aggressive overhead smash, that reaching backhand you stretched for — those are all asking a great deal from a very complicated joint: your shoulder.
In my practice at TruOrtho in San Antonio, I am seeing more and more pickleball-related shoulder injuries. And many of them — when caught early — do not need surgery at all. When they are ignored? That is when we end up in the operating room.
Americans play pickleball (2023)
of rotator cuff tears occur in people over age 40
Americans seek care for rotator cuff injuries each year
return to sport after surgical repair with proper rehab
What Is the Rotator Cuff, Anyway?
Think of your shoulder like the world's most versatile crane. It can move in nearly every direction — up, down, forward, backward and in full circles. That is extraordinary. But with all that freedom comes a tradeoff: the shoulder trades stability for mobility. The group of four muscles and their tendons that hold your arm in the shoulder socket and power all that movement is called the rotator cuff.
Those four muscles — the supraspinatus, infraspinatus, teres minor and subscapularis — wrap around the head of the upper arm bone (the humerus) like a cuff. Together, they keep everything centered and coordinated when you move. When one of them tears — either partially or all the way through — the shoulder starts to break down in ways you will definitely notice.
Why Pickleball Is Harder on Shoulders Than You Think
Pickleball involves repeated overhead and cross-body movements — every serve, every dink shot, every overhead smash loads the rotator cuff. Add to that the quick lateral movements, the tendency to reach out of your comfort zone for a ball and the fact that many players come into the sport without any sport-specific shoulder conditioning, and you have a recipe for overuse injury.
Here is what makes it especially sneaky: rotator cuff injuries rarely happen in one dramatic moment. More often, the tendon wears down gradually — like a rope that has been fraying for months before it finally snaps. By the time pain becomes noticeable, the damage may already be significant.
WARNING SIGNS YOU SHOULD NOT IGNORE
Pain at the top or outside of your shoulder that gets worse with overhead activity, weakness when lifting your arm to the side, pain that wakes you up at night when you roll onto that shoulder, or a dull ache after playing that used to go away but now lingers for days — these are the signs that your rotator cuff is trying to tell you something. Listen to it. Keep moving gentle, but contact us.
Non-Surgical Options First — I Mean It
Before anyone starts worrying about surgery, let me be very clear: the majority of rotator cuff problems are treated without an operation. My first line of treatment almost always involves a combination of active recovery and expert guidance.
Physical therapy is powerful. A skilled physical therapist can help correct movement patterns, strengthen the muscles that support the shoulder and reduce inflammation in a way that gives your tendon a real chance to heal.
Airrosti is another tool I often recommend to my patients. Airrosti practitioners use hands-on soft tissue treatment to address the connective tissue around the injury — often getting patients feeling better faster than traditional approaches alone. For early-stage rotator cuff issues and shoulder pain, combining Airrosti with specific exercises can genuinely change the outcome.
Active rest, activity modification, anti-inflammatory medication and targeted injections also play a role. The point is: we try everything reasonable before we talk about surgery.
When Surgery Becomes the Right Answer
Surgery for a rotator cuff tear is not a failure. It is a solution — often a very good one — when the right circumstances exist. I recommend surgical repair when:
- An acute, complete (full-thickness) tear is confirmed on MRI, especially in an active patient
- Conservative treatment (physical therapy, injections, rest) has been tried for 3 to 6 months without meaningful improvement in a chronic tear
- The tear is getting larger over time (yes, they can progress)
- Significant weakness is affecting daily life or athletic function
- The patient is young and active, and waiting would put them at risk of a larger, harder-to-repair tear
What Rotator Cuff Surgery Actually Involves
Modern rotator cuff repair is done arthroscopically — meaning I use a tiny camera and small instruments inserted through very small incisions. There is no large open cut. The torn tendon is reattached to the bone using small anchors, and the frayed or damaged tissue is cleaned up.
Patients go home the same day. You will be in a sling for several weeks to protect the repair while it heals. Full return to sport — including pickleball — typically occurs between 4 and 6 months after surgery, depending on the size of the tear and the quality of the repair.
A NOTE ON LONGEVITY
I often tell my patients: the goal of surgery is not just to get you back to pickleball next season. The goal is to keep your shoulder healthy enough to play pickleball in to your older years. Movement is medicine. Protecting your ability to move is one of the most important investments you can make in your long-term health and quality of life.
Prevention: The Best Game Plan of All
If you want to play pickleball for decades, start now. Work with a physical therapist or a sport-specific trainer on shoulder strengthening — particularly the rotator cuff muscles, the scapular stabilizers and the posterior shoulder. Consider adding Airrosti maintenance sessions if you are playing multiple times per week. Warm up. Cool down. Do not ignore early warning signs. Your shoulder is your partner in this sport. Treat it accordingly.
Shoulder pain affecting your game?
Schedule an evaluation with Dr. Jamie Lynch at TruOrtho, San Antonio.
Book an Appointment: www.sportssurgeryspecialist.com | (210) 878-4116
REFERENCES
- Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clinics in Sports Medicine. 2012;31(4):589-604.
- Millett PJ, Warth RJ, Philippon MJ, et al. Response of the rotator cuff to stress: an evaluation of outcomes in athletes. American Journal of Sports Medicine. 2006;34(10):1591-1598.
- Dunn WR, Kuhn JE, Sanders R, et al. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2016;25(8):1303-1311.
- USA Pickleball Association. 2023 Pickleball Fact Sheet. usapickleball.org.
- Yamaguchi K, Ditsios K, Middleton WD, et al. The demographic and morphological features of rotator cuff disease. Journal of Bone and Joint Surgery. 2006;88(8):1699-1704.
This blog is for educational purposes for personalized medical advice you must see me or another qualified physician for diagnosis and treatment of any medical condition. | Dr. Jamie Lynch, M.D. | TruOrtho, San Antonio, TX | www.tru-ortho.com | www.sportssurgeryspecialist.com
