17 North Beach Street
Nantucket, MA 02554
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Going To Court
Written by Bruce A. Percelay
Photography by Kit Noble
The Twists and Turns of Racket Sports
Rocco Monto is an orthopedic surgeon at Nantucket Cottage Hospital and a part of the Mass General Orthopedic organization. He trained on a clinical research fellowship in sports medicine and knee and shoulder reconstruction and is a founding team physician for the U.S. National Soccer Team, based on his early career as a professional soccer player.
Could you talk about your sports background, which I assume led to your medical specialty?
I was a professional soccer player myself and have been taking care of professional and amateur athletes my entire career. I have worked with Olympians and professional athletes in almost every sport, including tennis. I had the opportunity to take care of Billie Jean King, Chris Evert, John McEnroe, and Lindsay Davenport, which has given me a strong perspective on the nature of tennis injuries.
Starting with tennis, given how many people have played the sport, what is your perspective on its safety?
We study injury rates based on 1,000 hours of play. Tennis logs in at roughly 50 injuries per 1,000 hours, which would be considered moderate. If you play 100 hours, you are probably going to pick up some minor injury, but those injuries are seldom catastrophic.
As the popularity of tennis has waned, what other racket sports have you followed that are filling the void? And what are your thoughts on them, relative to injury rates?
Squash has continued to grow in popularity and is the most dangerous of racket sports. It is a much more intense game than tennis. Rallies are short and the VO2 max (which means cardiac output) of the players is higher. It is an intense sport, and all of a sudden, we started to see a different pattern of injuries like those to the eyes, which makes sense, given the proximity of one player to another, and the size and density of the ball. A lot of squash injuries relate to wrists, elbows, and ligament ruptures based on the intense cutting that happens on a squash court. It is also a sport that sees almost 100 injuries per 1,000 hours, which is double that of tennis.
Let’s move on to paddle tennis, otherwise known as platform tennis.
The sport is very popular in the Northeast because people can play almost year-round. Again, it is a much smaller court than tennis and is one that attracts older players. It requires quick movements, though not as intense as squash, and has a higher injury rate among older female players. These injuries include broken wrists, upper extremities, and shoulder fractures. It does, however, lack the intensity of other racket sports, which reduces the injury rate.
Clearly the hottest new sport is pickleball. Give us your thoughts on the explosive growth of this game.
The sport was the product of the pandemic and actually started in the ’60s but became wildly popular when people could not socialize inside as a result of COVID-19. All you need to do is take five minutes on a pickleball court and you will see what the problem is. You have a hard physical surface, four people of mixed genders and mixed ages within 15 feet of one another, often hitting the ball as hard as they can at the opponent. When you play pickleball, you are reacting and cutting at a very quick pace, which is fine if you are 25 or 30. However, when you look around at a pickleball court, it’s hard to find anyone under 60. I was out on the courts on Macy Lane, and every single person I saw was 60 and above, whipping the ball at each other, running around intensely, and it is an accident waiting to happen.
Can you quantify the injury rate of pickleball?
Through the Consumer Product Safety Commission, the government has created a National Electronic Injury Surveillance System (NEISS) that can check the injury rate of particular sports. In the last five years, I would estimate that there has been a 900 percent increase in the number of fractures reported by pickleball players. Most of these injuries are for people who are older, who are falling and breaking bones.
Are these gender-related injuries?
Absolutely. Women are the No. 1 issue of concern from my personal experience. It is such a huge concern that UBS Insurance has prepared a report on it because the insurance losses from the emergency room are alarming. It is estimated that the cost of all pickleball injuries on an annual basis is somewhere between $400-$500 million a year. It is a sport that is targeted towards older players, many of whom are not prepared. In the case of women over 60, for pickleball, paddle, or squash, they should have bone density tests. If they have osteoporosis, they should be treated by their physicians. It is non-negotiable for people in general, and women in particular, to play these kinds of sports without knowing what shape your body is in because with osteoporosis, when you fall, you have a serious fracture opportunity.
Is the concern the same with men?
Obviously, age plays a role, but men are more likely to develop cardiac problems or tendon issues. I strongly recommend that strength training be a part of a person’s routine before they play strenuous court sports and that people have EKGs and understand their physical condition before they jump on a court, especially if they are in their 60s or 70s.
What other preventive measures do you recommend?
I think almost every single patient I have has a vitamin D deficiency, which leads to a high percentage of muscular injuries. Making sure you have appropriate nutritional supplements like vitamin E or, in the case of women, calcium supplements is important. Flexibility is also critical, so stretching and warming up is extremely important. Yoga is a great way to stretch and is a smart way to prepare for strenuous court sports as well as other forms of cross-training.
Has pickleball been a boom for Nantucket Cottage Hospital?
Unfortunately, yes, and for me in particular. It is a sport that keeps me very busy, but many of these injuries could be avoided if people took seriously their physical condition before they jump on a court.
It has been said that the most dangerous sport in Nantucket is women walking on the cobblestones in heels or platform shoes.
I am sure you are asking this partially in jest, but the fact is, we see about 500-700 lower extremity injuries from people, mostly women, injuring themselves on the cobblestones with inappropriate footwear. My office has an entire rack of walking boots, and we could go through them every year from fractures and sprains on cobblestones.
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