| Dr. Corey

Repetitive strain injuries in gaming may threaten your career

Physical injuries in competitive sports are a common risk that every athlete must take to compete, and esports athletes are no exception. While practicing, streaming, and/or competing, gamers are prone to injuries that can limit their ability to perform, and in some cases, these injuries can stop them from gaming completely.

Repetitive strain injuries in gaming are among the most common ailments. In this article, we get into the pathophysiology of these injuries and teach you how to prevent them from occurring. If you’ve developed a repetitive strain injury, we’ll also teach you how to successfully rehabilitate.

The most common injuries

As already mentioned, repetitive strain injuries (RSIs) are among the most common ailments in gaming. Fortunately, they are easy to prevent. Chronic (developed over 6 weeks or more) RSIs occur in the tendons of muscles secondary to overuse, or imbalance, in conditions categorized as tendinosis injuries.

Tendinosis describes the process of tendon degeneration that is seen in RSIs. The term tendinitis is a common misnomer. Ailments ending in “-itis” imply inflammation.

In an RSI, there is no significant inflammation or inflammatory process, so the suffix -itis is inappropriate. This fact becomes extremely important for the appropriate preventative steps and treatment protocols of the condition.

An RSI occurs from repetitive imbalance in the contraction of a muscle and, of course, its tendon. This occurs in both PC and console gaming.

These injuries are all a response to the same mechanism—imbalance!

In PC gaming, the imbalance is most often caused by poor hand position combined with the lifting of the fingers off the mouse or keyboard rather than the striking of the buttons.

In console gaming, the imbalance is most often caused by poor hand position combined with the pressing downward on the buttons.

Concentric vs. eccentric contraction

In RSIs, the imbalance mentioned above is two-fold. The primary imbalance is in the type of muscle action performed. The shortening of a muscle while under tension is called the “concentric” phase of muscle contraction (i.e. pressing a button on a controller).

The lengthening of a muscle under tension is called the “eccentric” phase of muscle contraction, and in all of gaming—PC and console alike—there are no examples of appropriate eccentric muscle contraction, and this is the problem.

Agonist vs. antagonist activation

The second part of the imbalance is the lack of use in the opposing motion of a joint causing a discrepancy in strength and tension. The muscles creating the primary action are called agonist muscles. The muscles that create the opposing action are called antagonist muscles.

For PC gamers, the agonist action is lifting the fingers off the mouse. For many PC gamers, there is not enough activation of the antagonist muscles that close the hands (the flexor muscles of the fingers, hand, and wrist).

In console gaming, the agonist action is the squeezing down on buttons and triggers. For console gamers, there is not enough activation of the antagonist muscles that open the hands (the extensor muscles of the fingers, hand, and wrist).

When the strength and tension of the muscles on each side of a joint are not balanced, the muscles may become overworked and injury will become more common.

Visual representation of parallel tendon fibers

Anatomy & physiology of tendons

A tendon transfers the force from a contracting muscle to a bone. Tendons are made up of strong, parallel fibers of connective tissue. When a muscle and its tendon are repetitively shortened but not appropriately lengthened under tension, the straight bands of the tendon may become jumbled, and the tendon develops adhesions. These adhesions cause the pain associated with RSIs.

Think of tearing apart a VELCRO® strip; when you contract a muscle/tendon that has adhesions, the adhesions pull apart, potentially causing severe, debilitating pain.

Prevention of repetitive strain injuries in gaming

To prevent an RSI or overuse tendinosis, you must prevent the tendon from forming adhesions. This is a relatively simple task which simply requires working muscles in the eccentric phase of contraction and counter-balancing the movement with opposing muscle activation.

Since there are no examples of appropriate eccentric muscle action in the act of playing video games, picture a simple biceps curl exercise (see below).

Pulling the weight upward is the concentric phase; the muscle gets shorter under tension. Lowering the weight downward in a controlled manner is the eccentric phase; the target muscle is getting lengthened under tension.

Performing the lengthening phase allows the tendon to be pulled straight to prevent adhesions in the tendon fibers. If you were to consistently pull the weight upwards and not lower it downwards, the muscle would be overused in shortening and adhesions will begin to form. This is what happens to the tendons in gamers’ hands and forearms.

picture of flexing a bicep musicle
The eccentric phase of muscle contraction is the lengthening of the muscle under tension. This example is the eccentric contraction of the biceps muscle.

At first glance, it seems counterintuitive to continue to use a muscle/tendon that has been diagnosed with an overuse condition. However, as previously explained, it is the imbalance of use in the shortening phase of a movement compared to a lack of use in the lengthening phase, and NOT simply using the muscle frequently.

Recovery from an already diagnosed RSI is most often a simple technique. This will be described in detail below. Unfortunately, most people suffering from an RSI do not properly take care of the injury on their own. In these cases, the injury becomes chronic and more difficult to treat.

PC gaming risk

As esports continues to grow, the term “tennis elbow” is sure to be overshadowed by the name coined from gaming due to its increased prevalence. “Mouse elbow,” or lateral epicondylosis, is the repetitive strain injury that commonly affects PC gamers.

The injury occurs from a combination of the wrist position resting on the mouse—a position which shortens the extensor muscles—and the lifting of the fingers off the mouse buttons—an action that shortens the extensor muscles even further.

PC overuse injuries are not due to the action of clicking the mouse buttons downward.

image of hand using a gaming mouse
“Mouse elbow” may become the new, most popular name for lateral epicondylosis due to its prevalence in gaming & esports.

The muscles that pull the wrist and fingers backwards (to the knuckle side) are called the extensor muscles, and they attach on the outer portion of the elbow collectively in the common extensor tendon. The common extensor tendon is the site of lateral epicondylosis.

The common symptoms of this condition are pain at the outer portion of the elbow worsened with extension or opening movements of the wrist and fingers. Pressing along this region of the elbow will also increase pain. Weakness may occur, which is often due to pain and unwillingness to move rather than an inability to contract the muscles.

Repetitive strain injuries in gaming

Console gaming risk

The common console RSI is also likely to earn its own name as gamers continue to get hurt. Medial epicondylosis, sometimes called “golfer’s elbow,” is an injury that occurs from a combination of hand position and the pressing downwards on controller buttons and triggers.

The muscles that pull the wrist and fingers inwards (to the palm side) are called the flexor muscles, and they attach on the inner portion of the elbow collectively in the common flexor tendon. The common flexor tendon is the site of medial epicondylosis.

The common symptoms of this condition are pain at the inner portion of the elbow worsened with flexion or closing movements of the wrist and fingers.

Pressing along this region of the elbow will also increase pain. Weakness may occur, which is often due to pain and unwillingness to move rather than an inability to contract the muscles.

Repetitive strain injuries in gaming

Treatment and recovery

Repetitive strain injury treatment protocols are well-researched in clinical trials, and evidence supports a protocol involving aggressive cross-friction massage to the affected tendon, heavy eccentric loading of the tendon, and heat therapy.

Below is an example treatment for mouse elbow.

Step 1: aggressive cross-friction massage

Using a firm surface (thumb pressure or a knuckle, for example), apply moderate pressure to the affected tendon and scrape perpendicularly across the tendon. Unfortunately, this maneuver tends to be moderately painful.

picture of grabbing shoulder for pain
A tendon suffering from overuse tendinosis or RSI has adhesions within the tendon matrix. Aggressive cross-friction massage to an affected tendon will break apart these adhesions.

Step 2: heavy eccentric loading

Following cross friction to loosen adhesions, the next step is to add resistance to the tendon and lengthen it under tension. This resistance should be moderately heavy in order to properly pull the tendon fibers taut.

For mouse elbow, this would involve holding a weight (dumbbell or other small, weighted object) in the palm of the hand with the wrist extended and elbow flexed. In a slow, controlled manner, allow the elbow to open and wrist to drop—pulling the tendon.

Lengthening a tendon with added tension pulls the tendon fibers taut, preventing adhesions from reforming following the aggressive cross-friction massage.

Step 3 – heat therapy

Using heat packs on the affected area should conclude this protocol. Generally, a heat pack should be used for 10-15 minutes. Adding a damp towel between the heat pack and the affected area will increase its effectiveness by creating moisture that penetrates further into the body.

Generally, people think to ice their ailments to relieve the pain. However, ice relieves inflammation, and in an RSI, inflammation is not the cause of pain.

Therefore, ice would not help this condition. In fact, icing the affected area may prolong the healing process. Heating the area increases blood flow, thereby increasing oxygen and nutrients needed for recovery. For an RSI, heat is more helpful than ice.

Prognosis of repetitive strain injuries in gaming

As painful and debilitating as RSIs can be, the prognosis is generally quite good. Proper diagnosis and treatment can lead to full recovery. However, if left untreated, RSIs could lead to long term, debilitating injuries.

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Disclaimer

This information is for educational purposes only and is not intended to replace the advice of your doctor. Esports Healthcare disclaims any liability for the decisions you make based on this information.

The information contained on this website does not establish, nor does it imply, doctor-patient relationship. Esports Healthcare does not offer this information for diagnostic purposes. A diagnosis must not be assumed based on the information provided.

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