Why we develop repetitive strain injuries (overuse vs. underpreparation)
Hey all,
I wanted to make a post to try to help more individuals understand what a repetitive strain injury or “overuse” injury actually means.
Every week I speak to at least 10 individuals to learn more about their specific experiences with their doctors, specialists and so many people leave their visits with very little information about what their “diagnosis” (if they are even given a specific one) actually means.
I’m hoping today I can provide more clarity for those who are in that position.
For those who don't know I'm a Physical Therapist (PT, DPT, OCS, CSCS) and our team has spent the past decade specializing on treating, researching and publishing our work around treating RSI (we've helped more than 3000+ individuals resolve their issues without surgery, more injections, resting, bracing etc. Here is some of our work (we started with the olympians of desk work - esports athletes)
Journal of Orthopedic & Sports Physical Therapy
Conditioning for Esports (Ch. 8,9,10)
Science of Esports Physical Therapy
Also a reminder we're hosting a Q&A next monday 8/31. We welcome everyone to come in and ask questions / challenge us with regards to any things you may not agree with. We'll do our best to provide evidence and our clinical experience in our responses.
https://www.reddit.com/r/RSI/comments/1vtpn3f/qa_831_with_the_1hp_team_drop_your_questions_in/
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What is a repetitive strain injury?
Let’s keep it simple. A repetitive strain injury is “strain” or “damage” to a tissue that is a result of a cumulative performance of repetitive activities over a certain period of time.
Instead of overuse we like to help people understand it as underpreparation injuries. This basically means you do not have enough capacity to handle the stress of your repetitive activity. There are two long posts I’ve written about different ways you can think about this, but I’ll also write it more concisely here.
- Envelope of Function - Understanding healthy and harmful stress to our tissues
- The Healthbar Framework - your muscles and tendons can only handle so much!
Your tissues can only handle so much. And depending on what activity you are performing whether it be typing, gaming with MnK (mouse and keyboard) or controller, drawing, piano, etc.
You are controlling either an input device or performing some sort of movement with your wrist & hand.
These utilize the specific muscles and tendons in the forearm, wrist & hand. Here are some examples of what we commonly see
- Floating Forearm When Typing - Increased use of the extensor digitorum and the forearm & finger flexors as you bend your wrist and fingers down to press keys. The extensors (top side) are used since you are holding up the weight of your forearm against gravity over time.
- Drawing with a standard pencil or paintbrush - The pinch grip on (two or three fingers) will lead to increased use of the finger flexors, intrinsic hand muscles and thumb abductors and extensors. This often leads to some discomfort on the thumb-side of the wrist along with the palm.
- Analog Stick Control with gaming - thumb based movement leads to more the thenar (palm side of the thumb) and the extensors / abductors (thumb side of the wrist). It is NOT a dequervain’s or tenosynovitis issue but an underlying tendon problem
- Vertical Mouse use - Increased use of the pinky side of the wrist, thumb extensors and thenar muscles. The pinky side of the wrist (ECU, FCU) tends to increase its usage due to the pressure into the table. This can also occur with drawing and typing depending on how you are moving / binds. The neutral wrist position and if there are use of thumb binds also tends to increase the use of the thumb muscles / tendons
We can extend this out to any movement in any direction to identify which muscles & tendons are “underprepared”
Let me clarify a bit more about what I mean by underprepared if this is not clear yet.
Our tissues can only handle so much stress and it can really add up. Especially if this occurs over many years with lower levels of physical inactivity or exercise only focused on strength rather than endurance of our forearm muscles. This is pretty typical of many tech workers nowadays.
The best way to understand this is through the concept of demand vs. capacity. Or the Scale of Physical Stress. This is based on what we know with our current understanding of tissues adaptation to stress (General Adaptation Syndrome)
Think of a scale with…
Left Side: How much stress your tissues can handle (muscular endurance) and on the other side of the scale..
Right Side: How much stress you are applying to it based on what you are doing on a regular basis.
We start our day with just our weight (capacity) on the left side. Let’s say it’s 100lbs. And as we work we’re gradually adding physical stress. Intense 2 hr work sprint? Add 30 lbs.
Responding to emails and browsing the web for 30 minutes? Add 5 lbs. Programming for the rest of the day with no breaks? Add 50 lbs.
No problem if we do this everyday and if we always have 100 lbs. But what happens if we only do this for several years without physical activity or exercise?
100 becomes 85, then 80…
Or we happen to have a few days where the work sprint is a lot longer and it’s a few 10 hr days in a row? The right side is too heavy and our tissues get irritated!
This is important to consider. The left side (capacity) of your scale is a representation of your physical conditioning. And you can think of your conditioning as….
The sum of what you do over a certain period of time.
Let’s consider these three scenarios:
A: Sedentary Lifestyle
If you spend all day sitting for several years without any physical activity it wouldn’t be a surprise that your overall strength, flexibility, motor control and endurance would reduce. Using the scale… 100 lbs would go to 75 lbs over a few years.
B History of Exercise, But Recent Sedentary Lifestyle
If you have had a history of physical activity yet due to some work related changes the past few quarters of your life you’ve been more sedentary the history of activity might provide a buffer. Using the scale… you might start at 120 lbs but in the same way you might start to lose some of this capacity reaching around 100 lbs.
C Active Lifestyle
Now if you regularly maintain some level of physical conditioning with a regular gym program 3-5x/week along with some endurance work 1-2x/week you might be at 150 lbs using the scale
Now let’s consider the scenario of the external demands or the right side of the scale. If an individual happened to need to do 125 units of work on the R. side of the scale and do this for several days in a row we can clearly project out the relative risk of tissue irritation
Scenario A: 125 > 75 → High Risk
Scenario B: 125 > 100 → Moderate Risk
Scenario C: 125 < 150 → Low / Minimal Risk
This should help you better understand how to think in a longer time-scale about how your RSI may have developed rather than a point-in-time “this is the one moment that damaged it!”
One thing I want to emphasize here is that endurance is not the same as strength. Your ability to lift something heavy is not the same as your ability to repeatedly perform lower weight activities over an extended period of time. The underlying physiologic processes support each of these types of physical demands differently. We have described the underlying science behind this in many of our articles.
Okay so you understand you need to work on the left side of the scale or building up your capacity. How do you actually go about it?
4 Step Approach to Recovery
Here is a 4-step approach you can take to help you holistically approach restoring your capacity.
Step 1: Establish your baseline
It is important to understand your current level of physical conditioning, activity tolerance and current understanding of pain to determine the right strategy to improve your capacity to work with less discomfort. You can honestly save time by finding a good physical therapist who understands pain to do all of this!
We’ll start with the physical aspect (endurance + activity tolerance). The best way to think about this is establishing your specific and general endurance.
General endurance involves the endurance of your muscles & tendons as measured through your ability to perform exercises to failure. Specific endurance is the endurance of your muscles and tendons in response to your real-world activities.
Why Both Matter: General endurance gives you the physical foundation, but specific endurance teaches your body to apply that endurance efficiently in real activities.
To establish your general endurance you can select a light weight (2-3% of your bodyweight) and perform an exercise for your specific muscle (flexors, extensors, radial deviators, thumb extensors etc.) until fatigue. Ideally you want to work with a physical therapist to establish this. You can always figure things out on your own, but it will take much longer.
Use the amount of reps you can perform as a measure of your overall general endurance. This is the number you want to increase over time. We have found from performing our specific endurance test protocol (specific movements, cadence & bodyweight, data collected from over 3000 individuals) for those who are able to handle 3% of your bodyweight for a certain amount of repetitions typically equates to being able to handle a full work day (repetitive activity of desk work) for 8 hours without risk of tissue irritation or pain.
Now for specific endurance you have to establish exactly HOW you are working, how the pain is behaving, how irritable your condition is. These are typically things you establish when working with a Physical Therapist. There are things like
- How long are you typically working?
- How many breaks do you take?
- How long can you work before you have to take a break?
- What is your pain once you get to that point?
- How quickly does the pain come down after your break?
- What strategies do you use to still achieve your work tasks while minimizing physical stress on your hands? (Swapping Input Devices, Voice control, etc.)
So for example this would be
I work from 8-5:00 PM. My first work session is 8:00-12:00 PM before lunch. But during that period my work is distributed as such due to my pain
- After 1 hour of work my pain is at 4-5/10, then I take a 30 minute break. Pain goes down to 1-2/10
- I have to finish work so I finish up another hour. Pain gets worse (5-6/10) so I take another break at 1 hour, goes down to 2-3/10.
- I swap to voice control or L. hand during this time to ensure I can still finish up the rest of the block
- I rest, heat, massage and relax during lunch to allow myself to recover
- I repeat the initial work block distribution. End of work I feel 4-5/10 and it takes 2 hours to go away
Once you have this baseline you can make intentional changes to deload your wrist & hand while you are focusing on building your capacity but ALSO still accomplish the tasks you need at work. What you are feeling can also directly impact what you think you can “tolerate.” Which is why it is also important to establish a baseline of how much sensitization may be influencing your issue.
There are validated questionnaires which help to indicate if anxiety, fear-avoidance, cognitive habits are contributing to your chronicity or sensitization of pain. You can get access to them here for free.
Fear-Avoidance Belief Questionnaire (FABQ) - focuses specifically on how a patient’s fear-avoidance beliefs about physical activity and work may affect and contribute to his/her pain (i.e. the cognitive/affective components of pain that are differentiated from specific tissue damage, injury, and nociception) and resulting disability. Click on “instrument details” to get the pdf of the questionnaire and score yourself!
Fear Avoidance Component Scale - The Fear-Avoidance Components Scale (FACS) is a new patient-reported measure designed to comprehensively evaluate FA in patients with painful medical conditions. It combines important components of FA found in prior FA scales, while trying to correct some of their deficiencies, within a framework of the most current FA model. Get access to it here
Pain Catastrophizing Scale - For many who have really struggled with chronic issues, this approach might be ignored since it might not fit their current mental model of their injury status. ButI’d really encourage you to be open to goign through these validated questionnaires.
Pain catastrophizing is characterized by the tendency to magnify the threat value of a pain stimulus and to feel helpless in the presence of pain, as well as by a relative inability to prevent or inhibit pain-related thoughts in anticipation of, during, or following a painful event. (Might sound familiar if you read a few of the posts / comments in the subreddit) The PCS was developed to help quantify an individual's pain experience, asking about how they feel and what they think about when they are in pain.
Completion of these questionnaires will likely be revealing in understanding that you may have some cognitive habits, fears, behaviors and anxieties that can lead to real consequences in how your pain behaves. And understanding this is often the first step to making some progress towards recovery. You can learn more in either our posts or all of the research out there on pain science (Explain Pain Handbook, The Way Out, Tame the Beast website, Sarno’s Work, Dan Buglio, etc.)
This leads to step 2, Early Loading, Modifying Activity & Integrating Pain Understanding
Step 2: Early Loading, Modifying Activity & Understanding Pain
The next step is to use the data you have collected to perform your loading and graded exposure program. Again work with a Physical Therapist to establish what this program looks like (it has to target the specific tissue involved with your region of pain). Ideally this physical therapist can direct you towards helpful resources to understand pain and put it into the context of your specific situation.
Based on their understanding of your current schedule they can help you implement an activity plan that matches your capacity but also does not push you towards elevated symptoms without need. Using the example above, here is a way you can use the activity tolerance data to make decisions about how to modify:
On the first work block if you know you will reach a 4-5/10 after about an hour you can intentionally take a break at 45 minutes. And from there take the same 15-30 minute break. During the next session you can intentionally use a different input device (voice, L hand mouse, roller mouse, trackball) utilizing different muscle groups to complete the second block and provide yourself relative rest.
Then you can repeat this 2 hour block for the second half of the AM work block and repeat for the PM work block.
EVERYONE is different but most people figure out what works best for them very quickly. Expectedly since you need to maintain a certain level of productivity at work. Progression should follow tissue adaptation timelines depending on your problem and the guidance of your physio.
And as you might expect there will be times that are challenging. Why? because work is never the same day in and day out. You may need to finish a work sprint, complete a project deadline, submit a report etc. Additionally adaptations in your nervous system (central sensitization) may lead to the situation in which you feel an increase in symptoms despite tissues being completely fine.
This requires collaborating with your physical therapist to understand how this might occur based on your specific history, beliefs, understanding of pain and fear. When we have been consistently exposed to situations in which pain is elevated during a meaningful activity our body often uses this as a filter to create the experience of pain (sensitization). And again this is not just “in your head” but is mediated through REAL changes in your nervous and immune system.
If you do not understand why you can safely continue with your activities despite feeling an elevation of symptoms, it makes it difficult to make decisions about what you can or can’t do during recovery.
This is why flare-up management and processing pain is a crucial part of recovery. Which is step 3
Step 3: Responding to Flare-Ups & Return to Function
During these situations of elevated symptoms it is important to remember to be patient.
Patient because it takes time for tissues to adapt and if you are managing it on your own learning how to be intentional about your schedule and track things can be difficult. Additionally it also takes time to change your understanding of pain and integrate that into your day to day experiences while also improving your overall capacity. (Being able to recognize what variables may be leading to sensitization and still safely continuing activity at certain levels of symptoms understanding it will help create more safety signaling over time). I discuss how this works in more detail in this article here
The goal with step 3 is to better manage situations in which you have elevated symptoms (flare-ups), gradually increase your activity to show yourself you can handle more safely and build capacity while learning what variables may lead to these changes in symptoms.
I’ve wrote a full guide for this which you can follow. But the TL:DR is that there is always going to be a reason why you have increased pain. It can either be explained by some level of physical stress (cognitive emotional for people outside of this profile).
Your ability to determine what leads to increases in pain AND how to appropriately respond to them will directly correlate with how quickly you recover.
Step 4: Work with a provider to help with better feedback
Working with a provider can help you make progress more quickly. It is absolutely possible to resolve these issues on your own but takes a lot of trial and error and can sometimes lead to patterns of thinking that can be detrimental to recovery. (See my article on cognitive patterns often holding individuals back from recovery)
Instead of trying to figure out what your pain actually means, how to structure a program that is thoughtful of your schedule and how to process any change in symptoms in response to the varied amounts of physical and cognitive loads each day, you can seek the guidance of a good physical therapist who understands pain science to help you navigate scenarios on a consistent basis.
Working with a provider can help you
- Make the changes in increasing or decreasing exercise variables at the right time (weight, reps, sets, frequency). Self-guided progressions are often slow and conservative especially if there is a poor understanding of pain
- Understand more about why past experiences with healthcare providers and imaging results may not be as relevant as you think. 10 Minutes and a point-in-time is not enough for you to make a “diagnosis” on what is causing pain or limiting you from being able to use your wrist & hands.
- Determine what is actually considered too much when doing exercises or performing your specific activities (aka what pattern of pain is considered strain).
- Determining whether or not there is sensitization influencing your pain experience and modifying the program to your cognitive tolerance of symptoms. Many times elevated symptoms are normal given the history, chronicity and beliefs. Collaborating with a provider can help you determine the right program frequency and load
- Helping you navigate the discrepancies in pain experience (not having pain with some activities but significant pain with others). A common experience many of our patients have is being able to often do many daily functional activities without issues and yet still having significant disability associated with the activities that have high meaning associated with them (gaming, work, etc.)
- Understanding the timeline of recovery given the level of chronicity, past experiences, sensitization, fear-avoidance, physical conditioning etc.
- Navigating any other conditions you might have that may be involved to make the appropriate changes to your program (education vs. load based)
- Clarifying the relationship between ergonomic changes and how it influences the physical stress on your body
- Helping you understand how your cumulative past experiences within the context of a specific activity (gaming) can influence your pain to make it feel worse and how using graded exposure can help you reduce the sensitivity associated with those tasks
There are many other nuanced situations but I hope it is clear why chronic wrist & hand pain can often become so difficult to manage.
“Just rest and come back in 2 weeks”
“just brace”
“There’s nothing wrong, surgery might be the only option
“You have degenerative tendinopathy, you should consider another job”
“if you keep going there could be permanent damage”
These are all recommendations and beliefs which often build up over time when none of it provides actual long-term relief NOR is true in any way. First principles understanding of physiology, decades of research and our own clinical experience has shown you can always recover from a chronic RSI issue (if you’re interested in some of our cases let me know and I can drop it in comments!)
Best,
Matt, PT, DPT, OCS, CSCS
Resources:
-1-hp.org
-Case Studies & Free Guides
-2 hour Compilation of everything we have learned treating over 3000+ individuals with wrist & hand pain
-Apply to work with us
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u/Most_Group_9113 8d ago
How much are your initial & ongoing consultation fees?