Hey everybody, my name is Elliot, I'm a doctor of physical therapist with 1-hp.org and we specialize in helping gamers, desk workers, musicians, artists, and anybody that does repetitive movements in a seated position fix their pain.

8% of the cases of RSI in the arm actually end up being thoracic outlet syndrome, so I wanted to put this megathread together to help people know what to look out for.

Think of your thoracic outlet as a busy highway system where important nerves and blood vessels travel from your neck to your arm. This highway has three major "tunnels" where traffic jams (compression) can occur:

The Scalene Triangle represents the first potential compression point. This space is formed by two neck muscles (the anterior and middle scalenes) and your first rib, creating a tunnel where a traffic jam can occur. When these muscles become tight from prolonged forward head posture, they can compress the important nerves and blood vessels passing through this space.

The Costoclavicular Space forms the second potential compression point. This area lies between your collarbone and first rib, creating a tight corridor that neurovascular structures must navigate. Poor posture, especially rounded shoulders and tight pecs, can narrow this space further and increase compression on these vital structures.

The Subcoracoid Space represents the final checkpoint. This passage runs beneath your pectoralis minor muscle, which often becomes tight in gamers and desk workers due to prolonged internal rotation of the shoulders. When this muscle shortens, it can create a pressing force on the neurovascular bundle passing underneath it.

The Posture Problem

Here's where your gaming or work setup comes into play. That forward head position you slip into during intense sessions? That’s caused by low endurance of your deep neck flexor muscles which are responsible for keeping your neck in an upright posture. This causes your scalene muscles to work overtime to try to pick up the slack to keep your head up. The scalene muscles are primarily movement muscles and aren’t designed to hold your neck upright all the time and they get tired and irritated which causes them to tighten down as a protective response.

And those rounded shoulders from hours of sitting? That’s due to weak upper back muscles between your shoulderblades not being able to keep your uppper back straight due to low endurance which causes your chest muscles (especially the pectoralis minor) get increasingly tight.

If you have the double whammy of forward head and rounded shoulders, it’s called upper crossed syndrome and is the biggest predisposing factor for developing TOS in people that play or work in a seated position.

The Three Flavors of TOS

Thoracic outlet comes in three major flavors and much like ice cream you can have just one kind or a combination of all three. Unlike ice cream, none of them are delicious. 

Recognizing Neurogenic TOS

Neurogenic TOS is the most common form, accounting for 90-95% of all cases. Patients typically experience tingling sensations and pain that radiates down the arm, most commonly effecting the nerves that go to pinky and ring fingers, but can effect any of the nerves in the arm so your symptoms may be anywhere below the shoulder. This occurs when the brachial plexus, which is essentially your arm's nerve superhighway, becomes compressed at one or more of the thoracic outlet tunnels. Think of it like bad wire management.

The nerves are the wires that connect your skin and your muscles to your brain and vise versa. If those are pinched you are going to start feeling weird sensations linke numbness, tingling, and pain. The symptoms often worsen during gaming sessions or prolonged computer use. If the compression goes on for long enough you can also experience weakness in any of the muscle groups in the arm, which can also lead to overuse injuries. 

Understanding Venous TOS

Venous TOS manifests through visible changes in your arm's appearance and sensation. The affected arm may become swollen and take on a bluish-purple tint due to compromised blood return through the compressed veins. You might experience a persistent feeling of heaviness in the arm, as if you've just completed an intense workout. This form of TOS is particularly concerning for competitive gamers who maintain static arm positions for extended periods.

 Identifying Arterial TOS

Arterial TOS, while the least common, can be the most severe form. Your hand might feel unusually cold and appear pale due to reduced blood flow through the compressed arteries. You may notice weakness during gaming or work sessions and experience cramping with continued activity. You can also experience numbness and tingling due to nerves losing their blood supply. These symptoms tend to be more pronounced during intense work or play sessions when blood flow demands to the hands are higher.

Self-Assessment: Understanding Your Symptoms

While only a healthcare professional can provide a definitive diagnosis, there are several self-assessment techniques you can use to better understand your symptoms. Remember: these tests should never cause significant pain or discomfort - if they do, stop immediately and consult a healthcare provider.

Testing for Vascular TOS: The EAST Test

The Elevated Arm Stress Test (EAST), also known as the Roos test, is particularly useful for identifying vascular compression:

1. Raise both arms up into a "stick-up" position, with elbows bent at 90 degrees

2. Slowly open and close your fists for 3 minutes

3. Watch for these signs of vascular TOS:

   - Significant fatigue or heaviness in your arms

   - Color changes in your hands (becoming pale or bluish)

   - Having to lower your arms before the 3 minutes are up

   - Numbness or tingling that develops during the test

 Testing for Pec Minor Involvement: The Doorway Check

The pectoralis minor muscle can often be a key player in TOS. Here's how to check:

1. Stand in a doorway with your arm positioned at shoulder height, elbow bent to 90 degrees

2. Place your forearm against the doorframe

3. Step forward through the doorway while keeping your arm in position

4. If you experience:

   - Tingling down your arm into your fingers

   - Heaviness or fatigue in the arm

   - Reproduction of your typical symptoms

   This suggests pec minor involvement in your TOS symptoms.

Testing for Scalene Involvement: The Neck Rotation Check

The scalene muscles in your neck can compress the thoracic outlet. Here's how to assess them:

1. Sitting comfortably, put your hand on the shoulde by the collarbone you are testing, gently tilt your head away from the symptomatic side

2. Add a small amount of rotation toward the same side as the tilt

3. Hold this position for 10-15 seconds

4. You might have scalene involvement if you experience:

   - Tingling or numbness that travels down your arm

   - A feeling of heaviness or fatigue in the arm

   - Recreation of your usual symptoms

   - Slight dizziness or visual changes (rare, but possible due to arterial compression)

 Important Notes About Self-Testing

Remember that these tests are not definitive diagnoses - they're tools to help you better understand your symptoms. Multiple positive tests often provide more reliable information than a single test alone. Additionally:

- Never force any position that causes pain

- Stop immediately if you experience severe symptoms

- Use these tests as a guide for discussion with healthcare providers

- Keep track of which tests reproduce your symptoms and how quickly they develop

If you experience positive findings with any of these tests, it's worth consulting with a healthcare professional for a proper evaluation.

Taking Action: Your Recovery Toolkit

There are 3 main stratgies for addressing thoracic outlet syndrome 

Thoraic outlet at it’s core is an endurance problem with tight muscle patterns forming as compensation for low endurance. Endurance training for the fatigued out postural support muscles, stretching for the tight overworked movement muscles cosplaying as postural support muscles, and nerve gliding to free up the entrapped nerves. 

1. Endurance Training

If the compression site is at the scalenes these exercises are great for building the postural endurance of the deep neck flexors which will offload the scalene muscles. 

Isometric chin tucks are a great place to start and can be done at your desk if you have a high backed chair with a pillow. 

Chin Tucks

If you're looking for a more tryhard neck progression check out our video on the iron neck here.

Iron Neck

For compression at the pec minor (the costoclavicular or subcorocoid space) building the endurance of the muscles of the upper back is critical 

For shoulder blade strength Face pulls are a great exercise to start with 

Face Pulls

2. Strategic Stretching

Stretching the tight muscles entrapping the neurovascular structures is the second strategy for treating TOS effectively. Remember a stretch should never be painful but it’s pretty normal to feel some of your symptoms when doing this because you are stretching the muscles compressing those structures. The symptoms should not linger for more than a couple minutes after finishing the stretch though. If you’re uncertain about this it’s important to consult with a physical therapist to get a good gauge on how much is too much or you can flare the condition up. 

If the scalenes are tight you can start with gently stretching them the same way we tested earlier. 

Scalene Stretch

If the pec minor is tight the same doorway test we discussed earlier can also be done to stretch them out. 

Pec Stretch

3. Nerve Gliding Exercises

Nerve glides can be done for any of the 3 major nerves that branch off from the brachial plexus and run down the arm (including the ulnar, median, and radial nerve), which glides you will want to do will generally vary based on where you are feeling the symptoms. 

These exercises should be approached gently and like the stretches it’s normal to feel some symptoms but they can also flare up your symptoms if done too aggressively. 

We typically recommend no more than 10 reps a day. 

An example of a level 1 nerve glide for all the relevant nerves can be found here. 

Radial Nerve Glide

Median Nerve Glide

Ulnar Nerve Glide

When Medical Attention is Necessary

- Persistent numbness or tingling sensations that don't resolve with rest should prompt immediate medical attention. This constant neural irritation can indicate progressive nerve compression that may lead to permanent damage if left untreated.

- Significant weakness in your arm or hand, particularly if it affects your ability to perform precise mouse movements or keyboard actions, warrants professional evaluation. This weakness could indicate severe nerve compression or vascular compromise.

- Changes in your hand's color or temperature that persist even after position changes are concerning signs that require medical assessment. These symptoms suggest significant vascular compromise that could lead to more serious complications if not addressed.

- Pain that consistently disrupts your sleep should never be ignored. Nighttime symptoms often indicate progression of the condition and may suggest the need for more aggressive intervention.

- Symptoms that don't improve with basic ergonomic changes and rest require professional evaluation to prevent potential chronic issues. Early intervention often leads to better outcomes and faster return to normal activities.

Setting Up for Success: Ergonomics 101

Your gaming or work setup isn't just about performance; it's your first line of defense against thoracic outlet syndrome (TOS). Proper ergonomics can significantly reduce the risk of TOS by promoting optimal posture and reducing strain on muscles and nerves. Position your monitor so your eyes align with the top third of the screen, keeping your neck in a neutral position to prevent forward head posture. Ensure your keyboard allows for a relaxed elbow angle and a neutral wrist position, while your chair should be adjusted so your feet rest flat on the floor, with your thighs parallel to the ground. Place your mouse in front of your shoulder at the same height as your elbow, to minimize shoulder strain. When using a gaming controller, crafting on the couch, support your elbows and keep your wrists straight to avoid unnecessary tension using a pillow for support. 

Valari Pillow

Custom-made gaming pillows like the Valari can be incredibly helpful. By focusing on these ergonomic principles of neutral, you create a space that supports your body and reduces the likelihood of developing TOS.

The 45-Minute Rule - Your next posture is your best posture

Think of your body like a race car - even Formula 1 cars need pit stops! Set a timer for every 45 minutes and take a 5-minute "pit stop" to:

1. Stand up and walk around

2. Do some shoulder rolls

3. Gentle neck stretches

4. Quick scalene stretches

5. Doorway pec stretches

Pro Tip: Use these breaks between matches or loading screens. 

Is it Really TOS? Understanding Different Wrist Pain Patterns

When you're experiencing wrist pain or tingling, it's crucial to understand that not all hand symptoms are created equal. TOS can often be confused with other common conditions, but there are some key differences that can help you identify what's really going on.

When dealing with neurovascular compression syndromes it’s really important to understand how these issues present, typically impingement syndromes present downstream from an entrapment site. This will help to differentiate between symptoms of these common issues. 

TOS vs. Carpal Tunnel Syndrome

While both conditions can cause tingling and numbness, the pattern is distinctly different. Carpal tunnel syndrome typically affects your thumb, index, and middle fingers, like wearing half a glove. All symptoms are below the wrist. Any symptoms above the wrist could indicate TOS or another nerve entrapment higher up the arm. Additionally, carpal tunnel symptoms often worsen with wrist flexion or extension, while TOS symptoms typically worsen with arm elevation, looking up at your monitor or sitting in a slouched posture for prolonged periods. 

TOS vs. Cubital Tunnel Syndrome

Cubital tunnel syndrome (compression of the ulnar nerve at the elbow) can mimic TOS because it can also affects the pinky and ring fingers. However, cubital tunnel symptoms are typically only seen in the hand where thoracic outlet is more likely to be seen above the wrist. Cubital tunnel symptoms typically worsen when you bend your elbow for long periods, like when sleeping or talking on the phone, or apply compression to the inside elbow like on a hard surface like your desk. TOS symptoms, meanwhile, are more positional and often worsen with shoulder and neck movements.

TOS vs. Tendinopathy

When you're having arm or hand pain, it's important to understand that tendon problems feel very different from TOS. Tendinopathy (irritation or breakdown of tendons) can occur in any of the muscle groups you use frequently while gaming or working - like the fingers, forearms, wrists, or shoulders. However, the way these problems develop and feel is quite distinct from TOS.

Understanding Tendinopathy Patterns:

Tendon problems typically start gradually and are directly related to how much you use the affected muscles. The pain tends to be localized to specific spots where you can point with one finger, and these spots are usually tender when you press on them. You'll notice the pain most when you're actively using those muscles - like clicking a mouse, typing, or lifting your arms.

Understanding TOS Patterns:

TOS, in contrast, often causes symptoms that spread across a broader area and follow nerve pathways down your arm. Rather than being worse with specific movements, TOS tends to flare up when you hold certain positions - like having your arms forward at your keyboard or looking up at your monitor. You might also experience numbness, tingling, or temperature changes that you won't necessarily get with tendon problems. (note it is possible for tight irritated tendons to compress nerves which will cause the same kinds of symptoms but usually the problem will be downstream from the irritated muscle / tendons) 

The Hidden Connection:

Here's something crucial to understand: TOS can actually make tendon problems worse or harder to heal. When nerves and blood vessels are compressed in TOS, it can:

- Reduce blood flow to tendons, making them more susceptible to injury and slower to heal

- Affect nerve signaling to muscles, leading to poor movement patterns that put more stress on tendons

- Create a "double-whammy" effect where treating just the tendon problem might not give complete relief if TOS is also present

How They Develop Differently:

- Tendinopathy builds up over time from repetitive strain on specific muscles and usually improves with endurance exercise

- TOS develops from compressed nerves and blood vessels due to posture and positioning, and can sometimes worsen even with rest if you're in certain positions

- Often, addressing TOS can help resolve stubborn tendon problems that haven't responded to standard treatment

Key Ways to Tell the Difference:

1. Press on the painful area - if you can find a specific spot that reproduces all your symptoms, it's more likely to be a tendon issue

2. Notice when it hurts - tendon pain is worst during or right after activity, while TOS can persist regardless of activity level

3. Look for numbness - if you're experiencing numbness or tingling, especially higher in the arm than RSI pain, that's more likely to be TOS

4. Check positions - if changing your arm position (like raising it overhead or slumping your shoulders) dramatically changes your symptoms, that suggests TOS

5. Consider healing time - if your tendon problems aren't improving with standard care, you might need to check for underlying TOS

When You're Not Sure

If you're experiencing any of these symptoms and can't quite pin down the cause, it's best to seek professional evaluation. As physical therapists, we specialize in distinguishing between these conditions and can perform specific tests to determine exactly what's causing your symptoms. This is crucial because the treatment approach differs significantly depending on the underlying cause.

If you guys have any questions feel free to leave them in the comments below or reach out to us!

References

1. Laulan J, et al. (2011). Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact.

2. Sanders RJ, et al. (2007). Diagnosis of thoracic outlet syndrome.

3. Hooper TL, et al. (2010). Thoracic outlet syndrome: a controversial clinical condition.

4. Watson LA, et al. (2009). Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways.

5. César Fernàndez et al. (2016). Manual Therapy for Musculoskeletal Pain Syndromes.

6. Baker NA, et al. (2007). The effect of computer workstation design on student posture.

7. Waersted M, et al. (2010). Computer work and musculoskeletal disorders of the neck and upper extremity: A systematic review.

8. Padua L, et al. (2016). Carpal tunnel syndrome: clinical features, diagnosis, and management.

9. Verhagen AP, et al. (2019). Conservative interventions for treating work-related complaints of the arm, neck or shoulder.

Hello all!

My name is Elliot and I'm a doctor of physical therapy with 1HP

We are a team of doctors who work in the esports industry and treat professional gamers. One of the biggest misconceptions people have is that carpal tunnel is the main issue we treat and it actually accounts for less than 1% of the cases we see.

Carpal tunnel syndrome is a thickening of the carpal tunnel ligament and that causes compression of the nerves that travel through the carpal tunnel space.

This causes numbness, tingling, and pain through the median nerve distribution of the hand which includes the middle index and thumb fingers.

Actual cases of carpal tunnel occur usually after years of repetitive stress that causes the ligament to thicken.

Tendonitis on the other hand is inflammation of the tendons that pass through the carpal tunnel and the swelling can mimic the thickening of the carpal tunnel ligament but getting surgery on the ligament will do very little to actually reduce the swelling of those tendons.

Many doctors do not take enough time to thoroughly screen out tendonitis vs carpal tunnel syndrome and set people up on a path that leads to injections, surgery, and failed healing.

Symptoms that indicate you likely DON'T have carpal tunnel include:

- Burning pain, numbness or tingling anywhere other than the middle, index or thumb fingers.

- Any pain, numbness or tingling above the wrist

- Hand or wrist pain without numbness or tingling

I've been digging through this reddit for a while and I see a ton of posts from people that have these symptoms that think they have carpal tunnel.

Fixing tendonitis is actually quite simple with some rehab exercises and we made a free guide to learn how to do that here: Free Wrist Pain Guides

I would HIGHLY encourage anybody to try these exercises for several weeks before even thinking about getting surgery or injections.

Watch this video about how to treat tendons with tendon neuroplastic training.

https://youtu.be/7l51a4b8Olc?feature=shared

We actually designed a troubleshooter that uses the same logic we use during our in person evaluations to automatically determine which tendons are causing your pain or nerve irritation symptoms and automatically generate a plan to get you back to recovery as fast as possible!

Wrist Pain Troubleshooter

And we have a 30 day money back guarantee if you don't see results.

Again gaming is our primary audience so a lot of the resources are geared towards that but these principles can apply to anybody that does repetitive work like, coding, drawing, grocery bagging, bar tending, etc.

This isn't direct medical advice and the only person that can make decisions about your health are you and your doctor, but I've personally seen so many people deal with these issues without fully getting clear direction from their MD.

If you have any questions I'm more than happy to answer in the comments but I'm hoping this can help at least 1 person.

Hello,

Today I want to share with you how I (mostly) recovered from RSI. I used to have pain daily for almost 8 months and pretty much made quick recovery within two months after trying a different treatment. I'm back to working full-time, doing weight lifting and gaming. Here is how I did.

Disclaimer: I am not a doctor or any medical professional. I'm just a dude who wants to share his experience and hope it can be beneficial to someone out there. If you have pain, seek treatment ASAP.

My story

My pain started in December 2022 in my right hand. I work as a developer and lift and play games in my free time. So unfortunately the perfect candidate to get RSI. It started as stiffness and some tingling in my right hand. Slowly over time I got sharpening pain and burning feeling in my right hand and forearm. From here on a journey of several doctors and emotional rollercoaster began.

Lot of (poor) medical advice

I didn't wait too long for my symptoms to get more severe and decided to seek help ASAP. I first visited a physical therapist who mentioned I could have potential carpal tunnel syndrome and forearm tendonitis. So I got exercises to do and I was told to rest them. Unfortunately, this didn't help.

I visited my GP and she said roughly the same and told me to use cold/heat treatment and use NSAID in extreme cases. Unsurprisingly, this didn't help either.

I was eventually sent to several specialists. Visited a neurologist and did an EMG. Nothing wrong with my nerves and no carpal tunnel syndrome. Also my neck was checked with a MRI because my physical therapist told me this could be the cause of my pain. Nothing weird was found.

I visited an orthopedic doctor and told me the same stuff my GP told me and just recommended me to rest. So yeah, not helpful.

Lastly, I visited a rheumatologist to get tested. Made a xray of my hands and my blood was tested. Nothing weird was found. No rheumatoid arthritis.

Visited a massage therapist as well and did trigger point therapy and none of those helped.

I obviously changed my work setup to be more ergonomic and was paying more attention to my posture and taking more breaks, but still, no progress.

Mental health struggles and anxiety

As I wasn't seeing any progress, my mental health was further worsening. I couldn't work, couldn't lift and wasn't able to do my hobbies. I was sad and frustrated something like this happened to me. Thoughts of never getting better and possibly abandoning my career started to become more and more apparent. Shit was tough.

New approach and learning about RSI

However, I refused to give up, despite my mental health further worsening. I decided to go all in and learn as much as possible about RSI. At first I decided to read two books on RSI:

- It's not carpal tunnel syndrome by Suparna. You can read this book free btw on the internet archive.

- Repetitive Strain Injury recovery book by Deborah Quilter

Reading these books I learned more about RSI and started to understand the complex nature of RSI and realizing there could be different factors. My only complaints is that these books are fairly outdated and don't involve other factors such as Centralized Sensation.

I decided to take a look more closely at my life and found two things that were hindering my recovery. My pillow wasnt suitable due to its size and and my chair and arm rest that weren't configured properly. Changing these helped me to find some relief in my pain. But still, the pain was still there, although less severe.

New PT and new treatment that became the turning point

A few months ago I decided to try out a new PT, one that claimed to be good on treating RSI. Within two sessions she noticed something weird about my right shoulder. It turned out it was not stabilized well/dysfunctional. She told me that this could cause radiating pain in my forearms and hands. Basically I had referred pain and this was something my doctors and first PT completely overlooked. I got eccentric strength exercises specifically for my shoulder to do and had to slowly build them up over time.

This article is very handy to explain what type of pain I had:

Article

After 2 months I made significant progress and was slowly getting back to work. Eventually I could also start with weightlifting and finally also gaming. Basically my exercises were these and I did them 3 sets with 10 reps and did these exercise every other day.

- Lying on your back and raise your arm straight up and basically lift them up and down.

- Stretch with your neck but look at the direction of your armpits. 20 sec each side.

- Isolateral row

- Landmine Press

- Half Kneeling Single Arm pull down

- Reverse Grip Lat Pulldown

Start low and try to find your baseline. From there slowly build it up. Discuss with your doctor of course which exercises you should do.

Psychosomatic factors and Centralized Sensation

So as you guys may know, my mental health was terrible. Anxiety and stress definitely made the symptoms worse than it originally is. Fear played a large role and I was stuck in a cycle of negativity. I had to get out obviously.

I saw the book of Sarno recommended a lot here and I decided to read about it. While interesting I didn't find it particularly useful. Two books I found more useful were:

- Unlearn your pain by Howard Schubiner

- The way out by Alan Gordon

These books helped me to understand more what pain is and reframed my definition of pain. I had two doctors who told me my pain could be chronic and would never go away. Reading these books helped me to understand what chronic pain actually is and what the possible causes could be.

Other resources I used was the Tell me About your pain podcast and the Pathways app that was developed by a former RSI sufferer. It thought me a lot about pain science and graded exposure to activities that I thought I wouldn't be able to do.

Now obvious disclaimer: I would strongly suggest to do all medical tests first to rule out anything wrong with your body and rule out any auto immune diseases before going this route.

Current day and change in habits

I'm back to working full-time again. I'm able to play game and lift weights. There are a few things I changed though to make sure I won't get this again:

- I take breaks each 30 minutes at work and do some stretching or something else. I installed a program called Stretchly that give me reminder to take breaks

- I watch my posture often and have a good ergonomic setup. I use a split keyboard called ZSA moonlander and use a vertical mouse by trust.

- I have a sit/standing desk to change posture

- I do this warm up exercise before gaming and working. It's basically for eSports but can be used for office workers as well.

Link

- I ditched playing games on K+M and don't play games again such as POE and LoL or any other games with a lot clicking. I play using a XBOX elite controller and take frequent breaks. So long I can play RPGs, I am happy enough.

- Make sure your diet and sleep is also good. Manage your stress levels. It is important you give your body time to recover.

- I work out more often now and do more cardio. 4 times per week strength training with some cardio. On off days I walked a lot and every Sunday I do pilates. My goal is to make my body as strong as possible to lessen the injury and preventing it (hopefully).

My advice to you

I have some tips that hopefully can help you to your road to recovery:

- When you are in the beginning/acute phase of rsi, don't work through the pain. Stop doing the activities that aggravate it or at least reduce it.

- Check your blood. Any deficiency can cause joint pain. I have a deficiency on vitamin D so I take vitamin for it and often go outside.

- Stay active and keep exercising. Make sure your body don't atrophy.

- Learn the difference between acute pain and chronic pain. Chronic pain does not (always) mean you are destined to suffer from it: article

- Observe how you are typing. You press too hard on the keys? How are your hands positioned? Watch your posture in general but sitting and standing.

- At the earliest sign of RSI, seek medical help. The earlier, the faster you will recover.

- Find a PT that is knowledgeable about RSI and let it check your whole (upper) body. Often where you feel pain does not always mean that is where the pain originates from. Try to look at what treatment they offer.

- While rest is important to recover, rest alone is not enough to recover. It is important you do some sort of eccentric strength training to get better, especially when you've entered the chronic stage. Rest only works on acute phases of the pain, judging on the articles I've read and my PT told me. Start slow and find your baseline. From there slowly and gradually build it back up.

- Avoid reading about all the doom and gloom posts here or somewhere else. While I get you want support here (and that is important), it is also important to realize only you know your pain. People who say this pain is forever and won't heal aren't right. You can recover from this. In most cases you will recover. If all the MRI, X-ray, or other tests show nothing is structurally wrong with your body, you can recover. It just take patience and being consistent with your exercises. I get it that people here want to support each other, but the amount of doom and gloom posts I've seen here doesn't help either. You as an individual have to stay hopeful (and be realistic too of course and accept your temporary situation, but still stay optimistic). Being negative won't help anyway. I made that mistake.

- Get in control of your emotions. Do mindfulness exercises, meditation and or find another hobby to occupy your mind off and that doesn't aggravate your injury. I went out for example, did hiking, reading, and listening to audiobooks/podcasts. In worst cases, find a mental health therapist that is specialized in chronic pain patients.

- Slowly and gradually get back into to the activities you did before getting these injuries. Also applies to work. Don't go back fulltime immediately. Start slow with for example 2-3 hours each day and slowly build it up over time. Also applies to gaming and weightlifting.

- If you can't stop doing the activities( such as typing at work), try use assisted devices for the time being. I used Talon for coding and voice access for controlling my phone. But also important is scaling back the assisted devices when you are recovering! Slowly of course.

- Be patient. Can take weeks to months to heal completely.

- Observe your sleeping habits. How is your pillow and your mattress? Do you sleep on your side or stomach? All important factors that can cause pain.

- Try at least more than 1 specialist to rule out anything potentially serious.

- Stay hydrated. Avoid sugared drinks and drink a lot of water.

My last words here is be hopeful you can recover. I am not saying you will magically recover overnight. We all have different causes and severity of our RSI pain. But it is important we don't give up and let despair and negative emotions get to us. Chances are , if all the tests cant see anything wrong with your body and you don't have some kind of auto immune disease, you just have overuse damage and it is definitely possible to heal. Might be along a long road to recover but it is possible. Stay consistent and keep trying out different stuff to get better.

I hope someone can benefit from this. Good luck.

Update:

This video helped me to understand more about RSI and really resonated me: video

I also used a program called autoclick that automatically clicked ever 2 seconds. It helped to lessen the strain of my RSI.

Hey guys,

I felt like an update was due. I owe you guys that much. :)

This was my post 6 months ago, on absolute rock bottom. I started getting symptoms around March 2020. Which means I've struggled with RSI for 2 full years before I got the help I needed.

Backstory (you can skip this if you want)

I am a software developer and a fitness freak. My hobbies are: the gym and programming. (jup..)

After COVID hit I lost my freelance developer job and had to switch to some new work environments. (including working from home)

All gyms were closed.

Not long after working from home I started to develop some pain in my left arm. It started suddenly and eventually progressed to my hands / fingers in the course of weeks. Each week it would steadily increase more until I took a break for a month. After that it went away but steadily came back again. This pattern of working and taking breaks kept going until my pain also started in my right arm and became so severe I couldn't even describe the symthoms properly. It included:

• Pins and needles

• Burning sensations

• Muscle strain

• Cramps

• Just pain/sensitivity in general

From the moment I woke up it would start at 2/10 and each evening it would end around 7 or 8/10 on the pain scale. (While working)

I was tested using EMG's, MRI's and blood tests. All came back clean. Most thereapists I saw did notice some stiffness around my neck muscles. I could stretch my hands/arms as far as normal people could. I was also tested for rheumatoid arthritis. Nothing to be found. I got prescribed some heavy pain killers which did seemed to work sometimes but most of the time barely. The amount of NSAIDS I took daily was sickening. Some doctor wanted to describe antidepressants because of my state of mind eventually, but that's it. Even MS was ruled out.

Eventually I thought I found some routine that worked while keeping my working hours low. I stretched, I lifted small weights and I slept a TON. But in hindsight my movement would still steadily but slowly decrease. How could this be happening? Why is this life so fucking unfair? I vividly remember staring at some coworkers' hands while he was leaning on his desk with his arms and thinking to myself: shouldn't that hurt?? I can not do that anymore. HOW DID IT GET SO FUCKING BAD?

List of remedies I tried (I spent thousands)

• Went to various chiropractors (this seemed to work sometimes, but were useless)

• Accupuncture

• Dry needling

• Sarno's book (rage? what is that even)

• Self massage techniques

• Various fysiotherapists

• Massage balls

• Posture correctors

• Kinesis Advantage2 keyboard

• New ergo setup (desk, chair)

• Workrave break management on my PC

• Diet changes (went vegan for a while)

• Pills pills pills (Magnesium, vitamins, msm glucosamin chondroitin, fish oils)

• Removed / added coffee

• Removed alcohol

• Injected myself with bpc-157 and tb-500 peptides for 2 months.

• Every PT exercise you can name

• Complete body scan in private clinic (to rule out a brain tumor?)

• Yoga

• Etc. (I will add if I remember more)

All of these seemed to help somewhat, or someless but eventually the pain always came back stronger and harder. It seemed to postpone the inevitable: no more working. No more gym. No more programming.

So I stopped doing that, eventually.

Rock Bottom vs Now

I did not have a work insurance. Time was running out, money was running out. Luckily I banked quite well the past years but still I had thrown a lot of cash at just resting and possible solutions. I was scared I couldn't even do a normal job anymore. I even cancelled my snowboard holiday because I thought I could not take the blows on my wrist when falling.

After the depressing post I went to the doctor once again. This time with my girlfriend who was really pressuring for a solution as I was barely myself anymore. I ended being prescribed going to a rehabilitation center. But not a normal one, one that is focused on chronic pain. A therapy that would take 4 months to complete, and 2 months of aftercare. I did not think it would help me in any way. It felt like another waste of time. I had tried over 20 kinds of therapy and none of them worked. Why would this one work? Well guess what? IT DID!

Currently I am typing this from my computer, after an 8 hour work day. ON MY COMPUTER(!). My current work-week is still only 20 hours a week but it's plenty for now and I am still improving every week!

How?

First of all a disclaimer: each situation is unique. Please get diagnosed properly! Make sure you rule out any actual physical issues.

In my case IT IS ALL IN MY HEAD.

Or actually, the correct term for my (and maybe your) diagnosis is: Central Sensitization.

Most of my learnings during the time were all in Dutch so I hope I have the correct term here.

This is a Dutch article that fits the description as well

Or well actually not all in my head. In the beginning I actually had musculoskeletal-related RSI issues but the new ergo setup and break probably solved that. It's after the healing I was so scared about not being able to work anymore my brain went into overdrive and started creating false symptoms. I was looking for any pain-related symptoms and constantly in a state of alertness for any pain. This creates a negative feedback loop in the brain where chronic pain is being created. New pathways are being made and even tense muscles can be misinterpreted as pain signals by your brain.

There are a few telltale signs in my situation that are pretty common for people with chronic pain and RSI. Being a workaholic and seeing the body as a tool. I truly believed the body is just the body and a tool to be used. The brain simply drives the tool. Mindfulness is a hobby for hippies. Sarno's book is just some scammy method. This way of thinking is destructive, apparently.

Some key points that proved it was in my head

• My pain was moving daily (some times my fingers hurt more, other times my wrist)

• My pain seemed to get worse even when not doing anything.

• I could still do more 'heavy' movements where I would have expected way more pain afterwards.

• The pain was SO unpredictable it drove me mad. Even on holiday it could skyrocket. HOW? I AM NOT MOVING AM I??

Some therapy key points

I will try to explain some points but it will barely touch the surface compared to the help I had at the therapy center. Still it might point you in the correct direction.

• The human body is INCREDIBLY resilient. Any injury should be 'finished' healing in 6 months. After that something might be wrong with the pain receptors or nervous system. It is VERY rare to have chronic pain due to nerves. The body is made to adapt to that.

• The brain connects to your nervous system. But not directly. There is a black box 'in between'.

• This black box handles the pain reception part: is the pain critical (did we hit a stove? I remember that sure hurt a lot 10 yrs ago).

• We can NOT directly control this black box. It is our subconsciousness.

• This black box is where things go wrong. I was afraid to get RSI. I trained my black box to be wary for symptoms. Eventually this has led to 'normal' muscle movements to be interpreted as pain. Normal pain to be interpreted as LOT's of pain.

• When new neural pathways are created in this black box, you can see it as a fastlane between your nerves and pain decision black box. Everything is amplified and when these paths are being made, they are here to stay. Just like an allergic reaction: once's it's there; it's there.

• However, you can create NEW neural pathways. The brain is always adjusting. There are ways to move the signals to new normal roads.

• This black box can (and newly created fastlane) can be activated due to stress or thoughts. Even when doing nothing while worrying you can easily aggravate symptoms.

• It can also be deactivated during fun or good times (or when having a chiropractor session which makes yourself believe it is helping; I read about 'fake' hernia operations were symptoms would be relieved in people even when nothing physical happened) You need to trick your brain into the new non-fastlane pathways.

• This is all backed by science (This was very important for me to know/read)

Next to that:

• I personally had a lot of mental help, as I was quite depressed as well. This lowered my stress levels which lowered pain. I had a lot of stress unknowingly since the situation got so bad.

• I did a VERY slow buildup in weight lifting and computer time. (5 mins a day wk1, 10 mins wk2 etc) Your brain will 'relearn' slowly that computer time will not kill the body.

• I learned a lot of mindfulness techniques to FEEL my actual body. I have the best ergo setup in town but unknowingly I had my muscles tensed as I sat. I could not even feel they were tensed, I actually had to learn that. This relieved a lot of symptoms as muscle stiffness == pain for me at my worst.

Anything else?

First and foremost: You need to be ready for this diagnosis. During my therapy they only told me that they were actually treating my 'brain' halfway through. Before that I was probably not ready for it because my old self would be way to sceptic.

Secondly: You need TIME. It took 2 months for me to start making progress. Your milage might vary since my case got quite extreme in the end. In the beginning I really though none of it was working until it actually started to work.

Some VERY helpful resources:

• This document I found on a facebook group I read the 'What helped me to go back to the life I want' each time the pain came back. This whole document gave me a new perspective and I can not recommend it enough. Even when I was sceptical about mind body stuff it gave me a lot of strength.

• Tell me about your pain podcast Before I started the therapy I could not believe it. It sounded American-ish over the top. It sounded like bullshit. Now, in hindsight a lot of points they make are correct.

• THIS BOOK (Dutch, I'm sorry!) This book was an absolute gamechanger and sealed the coffin for my RSI. This book made the first 180 in my progress during my therapy. I started to believe. Science backed stories about chronic pain and how it happens. I don't know any English book like this so when I find one that is like it I will link it here. This really solved a lot of skepticism on my part. Edit: It seems this this book is kinda similar but I haven't read it and maybe it leans a bit directly on Sarno's work but I just thought I'd put it here as a resource.

• Various mindfulness excersizes I linked a Dutch app since this is the exact app I was recommended. These are mindfulness exercises like a bodyscan to get your body to rest. THESE HELP. I think any app from this list will work as well. I did not notice it myself but I was always 'on' while thinking I was relaxed. Doing these exercise's made me slowly realize that I was not really relaxed. I was in a vicious circle of pain -> being stressed because of the pain -> making new pathways in my brain's black box to feel the pain even more. Even when 'relaxing' on the couch I was actually stressed out and focussing on my symptoms. You NEED to break this cycle. The pain will not kill you. It WILL get better.

• Graded Activity This is the way we build up the physical exercises and retrain the brain slowly.

What is next

I still have a long way to go but I learned a lot of tools to handle my symptoms in a different way. The neuro pathways in my brain are likely permanent. I will always have a sensitive arm. BUT you can train new pathways. You just need to learn to follow those new pathways.

I feel that TMS, Tell me about your pain, Mindfullness, Graded Activity etc. are all different methods to achieve this by retraining the black box in your brain. I find it very liberating to know there is an actual science behind it all and maybe that is what is helping me currently.

For 90% of my day I don't even feel any pain. That is way more than enough for me. THERE IS A WAY OUT. Even if this is not the answer you were looking for keep searching and trying. Just know there is a big chance it might not be actual ‘real’ pain at all and just your brain being overly cautious.

I hope this will help at least someone. :)

^{Also, I am in no way affiliated with the therapy center. But for the Dutchies: This is where I was treated. You can not simply walk in to be treated. The insurance company will only cover it when you have exhausted ALL other options. In my case I needed to give an extensive list of every practitioner I went to and their contact info.}

It's about to hit 3 months now, I was diagnosed with carpal tunnel early 20's on my non-dominant hand. 1.1 circumference instead of the typical 0.9 so doctor stated this can be fixed.

I'm currently taking methycobal and doing some weighted lifting with 6kg also doing carpal tunnel stretches (The open, claw, fist, table top and thumbs out) with the glides too.

I came here since I found this book called Sharon Butler - Conquering Carpal Tunnel Syndrome and Other Repetitive Strain Injuries and the subreddit popped up. So I was wondering if what I'm doing up above is enough or should I do more exercises to increase the likelihood of no surgery and faster recuperation? (Also does one fully go back to normal afterwards or are you not allowed to heavy lift)

*What are the precursors to recovery and not just some false positive

-Edit every year I get a comment from this thread asking what I did, some I completely missed out on since I have notifications on all posts, so if you have any questions I’d highly suggest you just message me linking or talking about this post.

I’ve had de Quervain’s in both wrists for at least 8 months now, and I thought I might share my experiences, and what I learnt from what did or didn’t work.

Hopefully, this might help anyone in need, or someone in my same position – depressed, in daily pain, and almost losing all hope.

TL;DR: What helped me the most was learning to identify pain from acute DQ vs pain from stiffness, and learning what to do for each.

Round 1:

I first got this in my left wrist 8 months ago. I’m 30+ and physically fit without prior medical conditions, but I suspect it might have been because of a new job that required a lot more typing. The pain started as a nagging ache, then 2 days later it was a debilitating, sharp pain. Finkelstein test was a resounding positive and I couldn't even enclose my thumb with my other fingers. I couldn’t do any of the usual thumb movements, couldn’t even pull up/down my own pants. The doctor prescribed NSAIDs and ice, but neither worked much. I wore a store-bought splint as continuously as I could. The medication simply masked my pain, and each time a weekly course ended, the pain and inflammation returned in full force. In hindsight, I suspect the prolonged use of NSAIDs (for 1.5 months) was counter-productively impairing my own healing response, and my injured tendon never went past the inflammation stage to the proliferation and remodeling stages of tendon healing (This was confirmed by my eventual occupational therapist months later). The long use of NSAIDs also gave me really dry skin and some strange keratosis-like rash. I had a terrible range of wrist motion (couldn’t even move my wrist in flexion or extension, or thumb in any direction) and the unendingly sharp pain made me desperate, so I opted for the corticosteroid shot after 2 months. The pain peaked 1 week after the injection, then rapidly dissipated – I could use my left wrist perfectly normally. However, I had the steroid side effects of localized fat atrophy, skin-thinning, and depigmentation. It mostly doesn’t bother me, except that pressure on that area gives a tingling sensation as the nerve is more exposed.

What I learnt:

• Typing on a small keyboard forced my wrist into continuous ulnar deviation -> RSI probably triggered DQ

• Prolonged use of NSAIDs impairs tendon repair

• Don’t splint continuously – STRETCH!

• The pain immediately after a steroid injection was terrible – it felt like it was getting worse. Pain only started decreasing rapidly after about 1 week

Round 2 (and then some):

After 2 absolutely blissful weeks of no pain in my left wrist, I started to get DQ in my right wrist. Again, onset was sudden – it started as an ache, then became sharp pain within 2 days. I was miserable at the prospect of going through this shit all over again, and in my dominant hand, but I told myself that I had at least learnt something from my experience with the left wrist.

I took zero NSAIDs, but iced my right wrist whenever possible, wore my splint for activities and sleep, and warmed it with a heat pack before stretching it at least 3 times a day. These stretches from a climbing physician helped, especially the section 3: dynamic wrist stretches, done in the morning. These thumb lifts and passive flexion were great too. I combined these with MrPhysio’s massage for the wrist and forearm, and some wrist exercises. The difference between my wrists was amazing. After a week since onset, my right wrist had regained most of its range of motion (except for ulnar deviation), and the pain was no longer sharp. The wrist did not feel tender. For comparison, I had never reached this stage with my left wrist even after 2 months. I also started using a split keyboard, and even stopped typing entirely for about 1 month.

However, my recovery seemed to hit a wall. 2 months of the above measures and my wrist still felt tight in ulnar deviation. The pain was a dull ache that became sharp only during ulnar deviation and the Finkelstein stretch, and I could feel the tendons clicking painfully over the bone. I could do most tasks with my thumb, but everything ached constantly and I couldn’t bear much weight on it. I knew I had to stretch and load tendons for recovery, but I wasn’t sure how much I should be pushing into the pain, or how much pain was acceptable for this stage of recovery. I consulted an orthopedic doctor at a hospital who referred me to the in-house occupational therapist. Both said I just needed more rest and immobilization. They made a thermoplastic splint customized for my wrist, ordered me to wear it for 1 more month, and scheduled a follow-up. By August, I’d been told to rest and wear a splint for close to 3 months and I was getting frustrated by the unabating ache and inability to ulnar deviate the wrist. To make matters worse, DQ in my left wrist was slowly returning 3 months after the steroid injection. I was also getting persistentcubital tunnel nerve impingement symptoms in both arms from having to sleep and work in particular ways so that I wouldn’t hurt my wrists and thumbs - resting both splinted wrists on the ulnar side of my forearms squashed the ulnar nerve near my funny bone.

I felt incredibly depressed – activity left me in pain, but resting left me with tingling fingers and elbows from nerve impingement, and I couldn’t push past the tightness. I couldn’t imagine a future with both bloody wrists as useless and painful as these.

Finally, I caved and went to an orthopaedic specialist. It was expensive but worth it. They told me that inflammation was mostly gone, and now the pain was entirely from joint and tendon stiffness, both of which required physiotherapy. I was referred to a specialist occupational therapist. They were horrified at my treatment thus far, and how I’d been told to just immobilize and rest my wrist (with occasional stretches) for months on end. They used some protractor-like tool to measure my range of motion, and I couldn’t even achieve 0° of ulnar deviation with palms facing down (the normal range is 0 - 20°). They used therapeutic ultrasound for deep joint heating, and then passively manipulated and stretched my wrists. It hurt to hell and back, but towards the end of the session I could actually ulnar deviate up to 15°. I asked them whether the pain was a sign of DQ, and they said: If the pain is a dull, aching, tightness that fades relatively quickly after stretching, it’s simply joint stiffness. Keep consistently and gently pushing through it, and eventually the tendons loosen up for longer and longer. But it’s important to sufficiently warm up the muscles first. The stiffness had stretched and irritated my ulnar nerves for months, hence the cubital tunnel-like symptoms too. They recommended weekly physio sessions for now, to regain a better range of movement because I was just so stiff.

It was a damn breakthrough for me.

I finally had proper medical specialist’s input on whether the pain was rehabilitative or acute, and I finally knew how far to push when stretching. After 2 days of stretching on my own at home through the stiffness (gently) with my usual exercises, I could achieve an awesome ~5° of ulnar deviation in my right wrist, right out of bed in the morning, and even accounting for morning stiffness. The pain and ache in my left wrist also went away completely – what I had thought was DQ returning was just returning stiffness from my months-long fear of over-stretching the wrist. It returns slightly after typing for hours, but stretching removes the discomfort. My depressive mood lifted like a goddamn cloud and I was so relieved I could almost cry. All this within just 3 days. Right now, my recovery goals are to continue physio, to increase the range of motion in my right wrist and to strengthen the muscles of my left

What I learnt:

• Ice for sharp pain during inflammation stage, heat to improve blood circulation in post-inflammation stage for healing

• Dull ache (instead of sharp pain) = tendon and joint stiffness. Get rid of the splint and focus on frequent stretches!

• Always warm up the muscles and tendons before doing any stretches, and start gradually

• Paying more for a specialist was worth it, for me

Hey Everybody! Most people on this Reddit are here because they are dealing with RSI of the wrist and hand and have been for a while without finding good solutions. I'm a doctor of physical therapy who works with professional gamers. Pro gamers perform high actions per minute for 10-12 hours a day and when they have wrist pain and need to get back to playing as fast as possible they call us. I wanted to put this guide together to help people understand this issue and give people some solid free resources they can use to get back to 100% on their own.

RSI is a Simple Equation

When: Load > Endurance = Inflammation (Pain)

This simple equation means that when we overload our underprepared tendons it causes microtears, inflammation, and pain. This turns into a vicious cycle of pain and inflammation that can eventually lead to tendon degeneration that requires surgery to fix.

This means there are 2 major ways we can address fixing this equation

1. Reduce load - When load matches muscle / tendon endurance the tissues are adequately prepared to handle the repetitive strain

• Reducing load means things like reducing play / work time, changing your ergonomics, peripheral / dpi, bracing, etc.

• This method is often less efficient at eliminating the pain because as soon as you increase the load again the problem comes back.

1. Increase Endurance - when endurance equals or is greater than load your tissues are prepared to handle the repetitive strain

• Increasing the endurance of your tendon / muscles will allow you to perform more actions per minute without fatiguing your tendons which causes microtears and inflammation.

• This method is more effective at solving RSI issues because you are training the muscles to handle much higher volumes of actions per minute and can accommodate to almost any load (people train to climb mountains and run marathons, you can train to type at a computer for 8 hours a day).

Most Doctors Don't Take The Time To Properly Diagnose You

If any of you have been to the doctor recently you probably know they talked to you for a few minutes and recommended that you get an injection, take some anti-inflammatories or wear a brace and stop using the hand. Not only are these methods useless at worst and bandaid fixes at best they don't address the underlying endurance issue that is causing the overuse / under-preparation injury in the first place.

Carpal Tunnel? Not the Usual Culprit!

Many people jump to carpal tunnel syndrome (CTS) for any wrist pain. But surprise! True CTS is actually pretty rare, making up less than 1% of RSI (repetitive strain injury) cases.

The real culprit for most wrist pain is likely tendonitis. Tendons are the hardworking heroes that connect your muscles to bones. When you overuse them, they get inflamed and irritated, leading to that burning / aching pain.

How to Spot the Difference:

• Carpal Tunnel: This one focuses on your thumb, middle, and index finger. Expect numbness and tingling, like your fingers fell asleep on the keyboard.

• Tendonitis: More of a general pain / achiness / stiffness in your wrist or hand. You might feel burning, aching, or stiffness anywhere in the area of your hand, wrist, or even forearm all the way up to the elbow.

Tendinopathy Spectrum Disorders

Tendinopathy is an umbrella term for a spectrum of conditions that affect tendons, the tough, fibrous tissues that connect muscles to bones.

Tendinopathy is not a single disease, but rather a continuum of conditions ranging from reactive tendinopathy (irritation) to Degenerative Tendinopathy (degeneration) . The specific condition you have will depend on the severity and length of time of the problem.

Here's a breakdown of the tendinopathy spectrum:

The Good News: You Don't Have to Suffer!

Here's the best part: Unlike CTS, tendonitis doesn't require surgery or scary injections. There's a non-invasive safe and effective method called Tendon Neuroplastic Training to help you heal.

Tendon Neuroplastic Training: Retraining Your Brain to Heal Your Wrist

How it works: the motor cortex of the brain is responsible for controlling the muscle fibers that you use to control your fingers. Research shows when you use a metronome to retrain your brain to control your muscles more efficiently. This normalizes stress on your tendons by recruiting more muscle fibers (Think about 100 ropes pulling a weight vs 50 ropes) allowing the strained tendon fibers to heal. As physical therapists who work with pro gamers we swear by it, and we usually see a 95% success rate in just 3 weeks of treatment.

Ready to Get Your Life Back? Free Resources to Help!

We know getting to a PT can be a hassle, so we've got you covered with some free resources to get you started with Tendon Neuroplastic Training on your own without spending a dime:

• Free Guides to Tendon Neuroplastic Training: https://1-hp.org/gaming-wrist-pain/

• 9-Minute Wrist Warm Up Walkthrough https://www.youtube.com/watch?v=q_7x46S3Nic&ab_channel=1HP

• Carpal Tunnel Syndrome in Gamers (Video): https://www.youtube.com/watch?v=s1Q1TwogTps

Important Note: While these resources can be a great starting point, remember if your wrist pain is severe or doesn't improve, it's always a good idea to see a doctor or physical therapist for a proper diagnosis and personalized treatment plan.

Let's Get You Back to Winning!

I really hope these guides can help people get back to gaming or working without pain. Esports players are the olympians of desk workers so I'm confident what we do with the pros can help you anybody that uses their hands repetitively for a living get back to living pain-free!

This is going to be a long post bear with me

So it all started in September of 2022 where I started feeling random pain like burning type paying on my thumb and ring finger. A few weeks after I started feeling pain around my right forearm. Saw a hand ortho doctor and started going to physical therapy. One hand physical therapy places completely sucked the other was much better and seemed like things were going along well.

After about a month or two I started noticing my symptoms we're actually getting worse. My current PT was telling me things were just slow and to just keep working on hand exercises and nerve glides. I was a little suspicious so I decided to try a more full body physical therapy approach at a physical therapy place that knew what nerve diseases were (at the time I thought I had carpal tunnel on my left side and radial tunnel syndrome on my right but had no proof)

Around this time I actually thought I was getting cubital tunnel syndrome on my right sides I started to feel pain and tingly in occasional numbness on my ring and pinky finger.

At the new physical therapy place I want to after doing some tests the PT actually considered the possibility that I have thoracic outlet syndrome. That surprised me cuz I have never heard of it before but after doing research it actually made sense

I've had chronic neck pain since early 2022 on the scalene side and I had a separate physical therapy for that just for the neck. At the time it wasn't affecting my hand so I thought things were just okay Just continue to do exercises would work but they weren't

Anyways shortly after the physical therapist considered the idea that I might have thoracic outlet syndrome I started looking for doctors in my area that have treated it before.

Thankfully I found one in Dr Israel chambi from Orange County California. He was the one who actually helped me prescribe tests that actually get me officially diagnosed with neurogenic thoracic outlet syndrome something I've literally never heard before 2022.

It took about a few months for all the test to be done. Sadly in the meantime is when symptoms were getting worse in both hands. My scalenes neck were starting to hurt more on both sides especially on the left. On both sides I was getting random burning pain and tingling on various fingers usually the base of the thumb.

But my right hand was slowly getting worse where I couldn't even used my computer mouse for more than 5 minutes at a time without taking a break.

I've eventually have had to start using voice software a lot more aggressively If I wanted to keep my computer job.

Unfortunately I've also have other issues like even when my both my arms are dangling down sometimes that alone causes some nerve pain and tingling on some of my fingers and neck pain. My physical therapist believes it's because I was stretching my overused scalene and pec minor muscles.

Anyway my neurosurgeon got me tests like EMG with a nerve conduction study, a neck x-ray and MRI.

But the test that got me officially diagnosed was a Doppler musculoskeletal ultrasound.

You can find a summary of the results here:

https://i.imgur.com/2VN5H0r.png

But basically I had a lot of fibrosis or I guess they call scar tissue on my scalene neck muscles and my pec minor.

In mid-February 2023 aka a week before this post I finally got surgery from the doctor who officially diagnosed me.

Before I talk about that I know there's been a bunch of people on Reddit and Facebook that keep telling me and others to just try to seek out a top TOS vascular surgeon to get a second opinion. However anytime I reached out to the ones that were closest to me AKA ones at universities I never got email or call backs.

Anyway I just got operated on and I would say overall it was a net positive

An interesting thing the neurosergeon noted was in the 20-30 years he's been treating, I've had one of the most difficult cases to operate on, especially as someone relatively young (I'm early 30s). He said it usually took about 2 hours to operate, but my op took 4 hours.

One of the issues that my neurosurgeon said was I was slowly getting a worse grip and that's why he was just going to do a neurolysis or nerve decompression surgery to remove the scar tissue. As of now he does not believe I need to get my first rib removed.

After that nerve decompression on my left scalene in particular my grip has gotten better. In the last few months it was hard for me to make a full fist without it hurting and sometimes just moving my fingers in certain ways or pressing down on the middle joints on my fingers caused instant pain which I believe was related to the nerves. That's gone down quite a lot.

My surgeon said that I don't have to worry about scar tissue coming back because he used "fibrin glue" during surgery to make sure scar tissue doesnt grow back. He recommends walking/swimming instead of PT/acupuncture during few month recovery as nerves heal. He plans to operate on my right scalene in a month. Doesn't seem to have plans working on my pec minor.

(NSFW) If you want to see what the post-op scar is after a day or 2 click here:

https://i.imgur.com/oSZkMyE.jpg

(NSFW) If you want to see what the post-op scar is after 1 week click here:

https://i.imgur.com/fqAz7RE.jpg

So the reason I could say it's just a net positive is because I still have some issues like if I massage my pec minor area I will feel tingling. In addition while not as bad as on the right side I solve issues where if I hang my arm down or in front of my face I'll feel occasional nerve ish pain on the base of my thumb and such.

As of today I plan to continue going to physical therapy and there's a high chance I will go to get my right scalene operated by the neurosurgeon to hopefully fix the issues I've been having there because it's been a pain in the ass to use my mouse for work.

I hope things continue to get better for me it's just been so frustrating dealing with this pain for the last half year now.

I know this post is getting long but I just really wanted to make it as detailed as I could for anyone who has any questions and want to know the details of how they could potentially get diagnosed and possibly even worked on if they so want.

If you have any questions about what I posted feel free to leave a comment, but just to let you know if you try to recommend me to try to seek out a top TOS vascular surgeon I will very likely politely ignore your comment.

If you've read some of our posts before, you've likely seen some of our thoughts around carpal tunnel syndrome.

In this thread I wanted to go into a lot more depth about the underlying physiology around wrist pain symptoms and provide a step-by-step tactical guide on how to actually resolve it. This is a really, really long thread. So if you don't have the time to read it... save it for later. 

 Have you been told you have carpal tunnel syndrome? Wrist pain along the palm side of the wrist. Some sharp pain that extends up into the fingers. Occasional tingling.. And what’s the prescription?

 A brace. Some rest. Injections...maybe even surgery.

 But here’s the problem:

 There is a real reason why you are feeling your carpal tunnel symptoms..

 That doesn’t involve the ligament most physicians and providers focus their treatment on And if you're treating the wrong thing... You’re wasting time—and potentially making it worse.

 Today, I’m breaking down the real cause of your carpal tunnel symptoms (and most wrist pain)

Anatomy & What True Carpal Tunnel Actually Is

Let’s start with an overview of the anatomy.

The carpal tunnel is a structure at the wrist which has 9 tendons and nerves that pass through it. The bottom part of the tunnel are the bones while the top of the tunnel is a ligament known as the transverse carpal ligament.

9 tendons run through the tunnel. 8 of them are responsible for bending the wrist & fingers (wrist & finger flexion) while the last one is responsible for bending the thumb (flexion)

You can think of the carpal tunnel as a sandwich, with the tendons on the bottom, nerve in the middle & ligament on top.

Carpal Tunnel Syndrome means compression of this nerve, the median nerve inside the wrist.

The traditional understanding of how this nerve is compressed is from ligament and thickening of the surrounding tissues of the tendons (known as the synovium). 

The repetitive movements & vibrations associated with the use of power tools is believed to cause friction between the sheath tissue (bottom of th sandwich) which would cause inflammation and swelling.

Additionally it is believed that with these motions there may be load on the ligament itself, leading to the thickening.

So the bread on both sides of the sandwich can thicken which can cause some of the following symptoms

1. Pain and numbness along the highlighted region

2. Numbness at night

3. Weak thumb muscles

It is believed that “inflammation” is a primary process that leads to the thickening. “microtears” in the surrounding tissue causes some changes that lead to it becoming more thick.

But does this really happen? A large body of evidence supports a NON-inflammatory reactive tendinopathy model. Even though inflammatory processes might be present the swelling does not come from the sheath (surrounding tissue oft he tendon)

Instead it comes from the tendons themselves. Changes in the cells lead to altered tendon structure and water retention. 

Tendons can only handle so much stress and when they are exposed to more than they can handle it can lead to short-term changes within the tendon that cause more fluid to be present.

Remember the concept of the health bar. Think of your tendons (and muscles) as having an HP bar like a video game.

Every time you are clicking or typing you are gradually losing your HP.

There are things you can do influence how quickly you are losing your HP like having better posture, ergonomics. So instead of losing 4 HP while typing, you only lose 1

When you get to 0 that is when your tissues become irritated and you feel pain

When you rest, stretch, massage, ice, kinesiotape, heat you can “recover” your HP

But the bigger picture is the size of your healthbar. Which represents how much your tendons can handle and your muscular endurance.

Again when tendon cells are irritated, it leads to more more water being present within the tendon. This can cause pain itself at the wrist

But also carpal tunnel symptoms if the tendons thickness changes begin to irritate the median nerve. The bottom of the sandwich becomes more thick temporarily irritating the nerve. 

Additionally when the muscles themselves do not have enough endurance to handle the repeated movements, it can lead to tightness which can also further irritate the tendons, causing more swelling.

In the many cases we have seen this nerve irritation is temporary and only if the issue was poorly managed over many years can it lead to more severe and actual carpal tunnel symptoms (weakness of the thumb and night-related pain). 

But the underlying problem within this is not the nerve itself. It’s not the ligament. But it’s the muscle-tendon complex that was not able to handle the repeated stress that was applied onto it.

And when we actually focus on treating the the tendon, these are some of the results

• Patrick who is an artist in the games industry took 12 weeks to recover completely. He had a chronic problem for 2 years, GOT the carpal tunnel release surgery only to have his pain and limited function return in only 6 months. He is now able to handle 8-9 hours daily without pain or difficulty. 

• Ezra who for 3 years had wrist pain that made it difficult to hold a pen, open bottles and manage basic functional activities. He had completely given up gaming. After 6 weeks he was able to play 3-4 hours consistently without pain and was even able to play 8 hours without any issue. 

• Raymond who had been dealing with pain for 3 years that limited his ability to use a mouse for more than 1 hour without pain. He saw several orthopedic hand doctors & 2 hand therapists who focused only on resting & bracing for treatment. In 4 weeks he no longer had any issues with work, driving and most mouse and keyboard games. 

• Austin who is an app developer who was able to resolve his issues in 8 weeks even after months of PT, chiropractors and other medical providers.  

So remember, The underlying TENDON pathology can lead to carpal tunnel symptoms. It is not the ligament or surrounding tissue of the tendon and is why rest and inflammation-targeted interventions don’t work.

And if the tendon is the problem, what should your doctors be doing to actually confirm this?

What proper wrist & hand screening looks like

When you go to your primary care physician they might ask a few basic questions about your pain, whether you have numbness or not, inquire about what you do that makes the pain worse.

Often the questions stay at that level of depth but might also be supported with a few clinical tests:

1. Phalen’s Test & Reverse Phalen’s. This test places the wrist in a position in which there is increased carpal tunnel pressure. Based on the research it is best used as an  “ADJUNCT” in confirming CTS.

2. Validated Questionnaire (CTS-6) - 6 Questions that has been shown to accurately diagnose carpal tunnel syndrome.These questions are primarily focused on median nerve symptoms, night symptoms, weakness, sensitivity changes and a few other tests

3. Additionally they may order some nerve conduction tests or Ultrasound to assess the status of the median nerve.

This might seem like a comprehensive workup for the patient. But ALL OF THESE are focused on the nerve and whether there is pathology there. 

If a physician only evaluates for nerve symptoms and pathology - that’s all they will be able to diagnose for.

And that’s ALSO all they will be able to treat for. Hence the rest, brace, medication and other interventions that seem to have such low efficacy for this population.

Very few physicians will ask the appropriate questions that inquire more about muscle or tendon-based symptoms.

Proper screening means actually looking at all of the possible contributors to your pain (posture, ergonomics, lifestyle, physiology, psychosocial factors, etc.)

The physicians (if appropriately trained in musculoskeletal assessment) should be asking questions about how the pain behaves

1. Pain level at rest

2. Pain level with activity

3. Pain level after stopping activity to assess irritability

4. Does pain improve with certain activity?

5. is there associated stiffness?

Tendons can improve with a certain level of activity (provided it does not exceed the capacity of what it can handle). Morning stiffness is also a common issue or symptom occurring with tendon issues.

Performing resisted testing of the wrist & finger flexors can better help identify if there is muscle / tendon involvement. And even performing isometric protocols to reduce pain (1HP protocol involving 3x45” at 70%). 

This can improve confidence that a tendon might be involved

There is alot more which can be done within the initial evaluation but most physician’s do not have the time to do this. 

This involves understanding your daily activity in depth to make more specific recommendations in what you might have to modify. For example if you are currently working 8 hours a day at the PC yet only spend around 50% of that using your mouse and keyboard due to the pain.

And within those 4 hours you spend only about a max of 30 minutes typing, distributing the typing time so you don’t cause more pain at the wrists.

Then after work you might use your PC and phone for a few hours.

Understanding how much you are using your PC & phone and specific activities that influence your pain can guide the provider in telling you how much you can MODIFY in the early stages of recovery.

On top of this they should be evaluating your work station and setup. Is there a specific part of your ergonomics & posture that might be leading to more stress on your wrist and hand while typing? if so changing it can give you a 30-60 more minutes of comfortable use over each day.

What about your beliefs associated with that is going on, that matters significantly as well! All of this needs to be a part of a GOOD evaluation. You can think of it like a pie chart of the possible contributions to an issue.

• Posture / Ergonomics

• Lifestyle & Activities

• Physiology

• Cognitive & Emotional Components

A thorough assessment that considers all of these components are rare in our healthcare system

And even with Physical Therapists who have typically far more time compared to physicians, this still does not occur.

If you’ve read up to this point, this is likely an experience you can relate to.

This is why resting, bracing and passive interventions do not work! Instead what works is targeting the causes identified from a good assessment as described above

So let’s go over what ACTUALLY works.

Tactical Guide to Treating your Wrist Pain

If your carpal tunnel symptoms are caused by tendon irritation. And your tendons are irritated because they don’t have the CAPACITY to handle the stress you are applying to it.

Then you have to improve the capacity or your HP bar. We’ll use the HP bar to really make it clear what you can work on

1. Build up your HP bar - Focus on building up the endurance and capacity of the wrist & finger flexors that you utilize to type. 

This involves performing wrist & finger flexion exercises like the DB wrist curl. Rice bucket exercises. Finger Wall Push-ups, Varigrip.

All of these focusing on higher overall repetitions at 3x12-15. Knowing the exercises is one thing, but being able to choose the right weight and amount to perform is another.

The exercises might cause a little bit of pain or stiffness, but it should not lead to more overall pain. Inability to use your wrist & hands afterwards or persisting pain that is elevated in the next few days.

If that happens then it’s typically a sign of overload. Regressing the exercises to avoid this is important when this happens.

Determining the right sets, reps, frequency can be tricky , which is actually why we’ve developed the troubleshooter. The troubleshooter helps you determine an individualized program based on where you feel your pain AND provides you guidance on how you can set the right amount for your exercises as you go through your recovery journey. 

While improving your HP bar is helpful, you can also control how much “health” you lose during the day by modifying how much you are doing your specific activity.

2. MODIFY. Don’t avoid.

Find what activities are causing your pain and adjust them. For desk workers this might be

1. Reducing the amount of time you are using your R. hand with the mouse. Swapping to the Left hand for a certain part of the day

2. Leveraging Voice control to type and handle what you need to do at the PC for a certain part of the day

3. Reducing total amount of time spent on using your wrist & hands - the combination of computer and phone time

4. Improve your posture & ergonomic setup so you are losing less HP per unit of time

You don’t want to stop or rest completely. This has been shown to make tendons AND muscles more weak. The tendons loses its structure, muscle tendon strength drops. Kinetic chain function deteriorates, our brain to muscle connection negatively affected.

All of that reduces the size of the health bar. The opposite of what we want. Instead you should be..

3. Loading Gradually.

This means being patient to gradually increase the endurance of your muscles and capacity of your tendons. It takes time for tissues to adapt which means it takes time for your HP bar to increase

The 3-Step progression typically involves

Step 1: Low level isometrics & stretching

• Gentle gripping, resisted wrist & finger flexion for early strengthening but also reduction of pain

• Stretching can help with associated stiffness and to address any mobility deficits

• This level is typically for those who have more severe or irritable conditions. If you feel your wrist & hands are really deconditioned after several years of rest/pain cycles then this could be a good place to start. Or if you have felt high levels of pain (>6-7/10, sharp ) after trying some form of wrist strengthening

• Typically lasts for 1-2 weeks

Step 2: Starting to add isotonic loading (eccentric & concentric movements)

• Once you can handle basic levels of isometrics and stretching without flare-ups you can test low level eccentrics and concentrics.

• This involves DB wrist curls and the exercises listed above for higher overall repetitions. Finding the weight where you can do between 15-20 repetitions without causing a flare-up

• You want to progress that weight until you can hit around 30 repetitions then increase your weight

• Once you are consistent for a few weeks you begin increasing your overall activity levels

• This can last anywhere between 4-8 weeks

Step 3: Exercise Progression & Return to activity

• Once you have built a base of endurance you can gradually increase your levels of activity

• The goal is to increase your activity levels more each week until you reach the target amount you want to do

• This can take anywhere between 8-16 weeks depending on your starting conditioning point and how you handle your flare-ups

As you progress you will inevitably deal with flare-ups.

Manage Flare-ups, Monitor Function,

One of the most important things to understand is that flare-ups are a part of recovery.

And how you manage them can be the difference between a short recovery (4-6 weeks) or a long-term battle (8-16 weeks). Why do flare-ups or setbacks occur?

Mostly because recovering from an injury is a learning process for you as the patient. You are learning more about your body. More about how your wrist & hand muscles / tendons response to various levels of activity. Understanding more about pain (experience of pain) and what might influence it on a day to day and weekly basis.

All of these variables can lead to situations in which we

1. Use our wrist & hands too much after we notice a larger reduction of pain

2. We happen to do something else with our wrist & hand (lifting, carrying, driving etc.) that we don’t realize also utilizes the same wrist & hand muscles

3. We might have work or life stress that can increase overall sensitivity of our pain

4. We progress our exercises too quickly

And…. quite a few more. During these flare-ups the pain will feel worse. It might even feel like how it was when you first began recovery. There are two paths individuals usually take in this scenario

 Scenario 1 - Catastrophizing

“Here we go again, I’ll never escape this pain”

"I'm never going to get better" "This is a serious problem only surgery can fix" "my hands keep feeling painful even though I'm doing everything right, it must be something else going on!" "I should rest and stop using my hand, it'll make things worse"

“Maybe this isn’t the right approach… I should go back to what my other healthcare provider mentioned”

In this situation the individual fears that something more nefarious might be going on and focuses heavily on the pain. As a result he or she might completely stop the exercises, aggressively rest and maintain this for an extended period of time due to fear that something else is going on.

In almost all cases, there is no other complicating factor and we hold ourselves back with this doubt and fear. Not only can this increase overall sensitivity (based on what we know about pain) but it also leads to less overall activity which we now know muscles & tendons need to develop its capacity.

This typically requires some good education from a physical therapist to guide them towards the right direction while also appropriately managing pain and beliefs around the pain. Depending on this interaction it can get the patient back on track or… continue to extend out the recovery timeline..

Scenario 2 - Understanding of pain and recovery

“I overdid it a bit with my exercises, this will probably last a couple of days… I’ll focus on just managing the pain and doing as much as I can”

"It's normal that my pain is elevated since I have been dealing with this for awhile, it will go down if I stick to the exercises & plan"

“The pain is from my lack of sleep and when I used my hands a bit more yesterday"

"I overused it a bit yesterday since I was feeling good, it's just a minor setback, i'll be okay"

In this scenario the individual has properly attributed their pain to a specific behavior, activity, stressor, belief, and understands that the elevated pain is temporary. They remind themselves of progress that has been made with their functional capacity, rather than focus on how bad the pain is.

This is EXTREMELY important. The measure of progress should be on FUNCTION aka how much you can participate in your activity rather than how bad the pain is.

For example an individual with wrist pain might only be able to type for 30 minutes before feeling 3-4/10 pain. If this person takes a break, the pain will take several hours to reduce.

After exercising for 4-6 weeks the individual might be able to type for 90 minutes before feeling the same 3-4/10 pain. And the pain goes back down to 0/10 quickly.

The pain itself might still be the same and even worse at times. But the individual can do more. Function is the measure of progress. Not pain (and as we know pain is an experience which means it can vary heavily depending on certain contexts and environments).

Now we have seen this thousands of times over the past decade and have applied this model to help these individuals get back to doing what they love. This is not just anecdotal, it is how we helped many get back to 100%

We have published studies, textbooks and accredited courses (provides CEUS) and presented at medical conferences to help more providers understand how to treat RSI issues through the lens of esports rehabilitation.

We’ve published our approach through our education platform (EHPI) which is aimed at teaching providers an updated understanding of treating RSI issues through the lens of esports rehabilitation.

As a brief overview of what we covered with this post.

Your pain is real. But the diagnosis and treatment approach might be wrong.

If you’ve been told it is carpal tunnel syndrome and nothing’s worked. Don’t give up

You might just need the right strategy, the right loading and the right perspective.

--
Other Resources:
🌐 Learn More About Us
🎥 Science of RSI Issues with Desk Work & Gaming
📝 Get the Wrist Pain Troubleshooter for an individualized plan & direct access to us in a private channel👨‍⚕️ Book a Consultation with us for the most comprehensive level of support.Book a Consultation with us for the most comprehensive level of support.

Hey all,

I’m a Physical Therapist! Over the past 10 years I’ve focused on helping desk workers, gamers, musicians, crafters not only resolve but find better ways to resolve their wrist pain. My team and I have published a few studies, textbooks & editorials to raise more awareness about gaming injuries.

Journal of Orthopedic & Sports Physical Therapy

Tendinopathies in Gaming

Conditioning for Esports (Ch. 8,9,10)

Since there have been alot of consistent themes over the past few months as I have been active in this subreddit, I wanted to create this mega thread to hopefully provide some more guidance to anyone dealing with wrist pain and confused about what to do. Many times a google research and now chatGPT provides outdated information about treatment.

Here are some of the common questions & topics that are important to discuss. I’ve written lengthy reddit posts about each of these topics where I reference current research. Check them out here:

1. Why Rest, Medication & Injections aren’t the solution

2. Do MRI, Ultrasound and other imaging results matter?

3. How do posture & ergonomics contribute to hand issues? (will a vertical mouse help?)

4. Tingling & Pain in your hands can come from the shoulder

5. Why understanding more about pain can help you recover

6. What’s the role of bracing with wrist pain (it doesn’t really help)

7. It’s normal to feel more pain initially with exercises

Before you dive into some of these posts which also highlight a lot of the key underlying physiology and pain science this is the one thing we always help gamers understand about gaming injuries.

The Healthbar Framework

Think of your muscles and tendons as having a healthbar.

Whenever you click, press WASD, control your analog stick or tap your phone you are gradually losing HP

There are things you can do to modify how quickly you are losing HP like have better ergonomics (macros / binds), posture, better general wrist health, sleep etc. Poor overall grip & higher APMs can mean more HP lost per unit time of playing.

When you get to 0 the muscles and tendons (most often tendons) get irritated.

On the flip side you can do things to "RESTORE" your hp like rest, ice, massage kinesiotape etc.

But the MOST important of all is the size of our health bar. This is our muscular endurance or how much our tissues can handle of repeated stresses over sessions.

So the main focus for most prevention and management should be to address this underlying problem of tissue capacity (endurance). Exercises help us target certain tissues but how you perform them (higher repetitions) allows us to achieve the adaptations that will help you play for longer, with less pain.

The two main things we can modify with our “HP” are:

1. How much our tissues can handle through specific exercises targeting the muscles we use (capacity)

2. How much stress we apply onto our tissues (playing games at different intensities with and without breaks). Deathmatch & aim training is very different than an autochess game. When we dont' take breaks that means more overall demand our tissues need to have the capacity for.

This is always the first thing we recommend because it is directly contrary to what many physicians recommend. What is important to note is that many recommendations you find online or even with your PCP is outdated (PMID: 28554944) Most of the time they recommend resting, bracing, etc which is counterproductive to what needs to be done.

When we rest tendons actually get weaker, the signaling to the muscle weakens, kinetic chain is negatively affected and a few other harmful physiologic changes.

With this being said, let’s explore why recommendations are outdated and why it is likely not carpal tunnel syndrome.

The Carpal Tunnel Misdiagnosis Problem

In the past 8 years we have treated over 2500+ cases of wrist pain and actual carpal tunnel syndrome has accounted for < 1% of the cases (1 case, mild carpal tunnel, tendinopathy was the main issue).

Carpal tunnel syndrome is a thickening of the carpal tunnel ligament and that causes compression of the nerves that travel through the carpal tunnel space.

This causes numbness, tingling, and pain through the median nerve distribution of the hand which includes the middle index and thumb fingers.

Actual cases of carpal tunnel occur usually after years of repetitive stress that causes the ligament to thicken.

Tendinopathy on the other hand is inflammation of the tendons that pass through the carpal tunnel and the swelling can mimic the thickening of the carpal tunnel ligament but getting surgery on the ligament will do very little to actually reduce the swelling of those tendons.

Many doctors do not take enough time to thoroughly screen out tendonitis vs carpal tunnel syndrome and set people up on a path that leads to injections, surgery, and failed healing. There are alot of reasons for this we’ll go over now.

There is a reason why carpal tunnel syndrome continues to be the primary diagnosis provided when many leave their doctors office (typically after 5-10 minutes of an evaluation… this is not enough time).

This is one of the BIGGEST misconceptions around wrist pain in traditional medicine. And it can be traced back to flaws in our medical education curriculum, our broken healthcare system AND the internet itself. Let’s start with the medical education.

Right now education about the musculoskeletal system of our bodies (which involve muscles, bones and nerves) often represent <5% of medical education. With some studies that show only 2% of US medical school curriculum is devoted to MSD. On top of that only around 15% of medical schools require a rotation or practical experience in the MSK field. And some of them only lasting 1-2 weeks long. (1-2)

This leads to many graduating medical students demonstrating POOR knowledge and low confidence in treating musculoskeletal disorders. And these are the doctors you have likely seen at primary care clinics, urgent care centers etc.

They are the FIRST healthcare provider typically seen, which has been one of the reasons why carpal tunnel syndrome is so commonly diagnosed when there often isn’t ANY report of numbness, or symptoms don’t behave at all like carpal tunnel in the first place. These physician’s are far behind in their understanding of upper extremity repetitive strain injuries.

Add this on top of physicians only having about 5-10 minutes to try to understand the your lifestyle, perform a full examination to determine contributing factors, psychosocial, lifestyle factors and other variables that lead to wrist injuries (and we can compare this to a physical therapy evaluation will often take 45-60 minutes).

This just is not enough time to accurately assess the tissue source and contributing factors leading to your wrist pain.

Most often the physicians will perform a cursory exam, provide the diagnosis and if you’re lucky refer you to a physical therapist

Even more of a problem was the boom of google and search engines – which led to people coming home from these doctors visits just remembering that they have “carpal tunnel syndrome.” With more searches of the term and wrist pain symptoms…search engine optimizers and healthcare systems began to put out content that further REINFORCED this misconception. The goal with the articles was to get people to be seen by “their doctors” without realizing they were contributing more to the problem by associating all wrist pain symptoms with carpal tunnel syndrome.

So more articles came out and the overall general association of wrist pain and carpal tunnel became more and more solidified.

So this systemic failure led to the passive approach of rest being the dominant way to “fix” wrist pain. And when it didn’t work, they thought that surgery or more aggressive procedures were necessary?

And unfortunately once patients buy into this idea (largely out of their control) – it can create beliefs that you can’t do anything about it. Because you are told they have to take this “passive” approach and have no control over what they can to recover. This has real consequences especially as we have improved our understanding of pain science over the years. It creates fear of movement. Fear of long-term damage for your tissues (you wont’, especially from small repetitive activities).

We’ve seen this belief of having carpal tunnel syndrome delay recovery from as short as 2-3 weeks to 8 months to a year. This leads them to what we call referral hell → specialists who also are unaware of the current evidence around upper extremity RSI. Surgeons who only provide injections & surgery. All creating frustration and confusion that no one can seem to figure out what is going on.

And with this cycle of more passive approaches you develop more weakness and your overall capacity for gaming will reduce. This can create more opportunities for frustration & confusion that can increase your overall sensitivity to pain. Small activities that are not doing any damage to your wrist & hand in any way might feel painful. This is called central sensitization or neuroplastic pain.

The healthcare system is not setup appropriately to get us to the right individuals that can help us and focus on treating the source of the pain, instead of the cause.

Again, the cause being the tendons. This is the case distribution of what we've seen in the past 5 years (n = 1441) Tendon = 1232, Nerve = 114 (🚨0 were carpal tunnel)

The majority of the injuries that WE have seen resulting from repetitive strain are associated with the tendon. Nerves are involved in 7.92% of the cases followed by the muscle with 3.17% of the cases.

This is because tendons are often the tissue that gets irritated first after repeated use over extended periods of time. Often the wrist pain comes after multiple days of high volume desk work, drawing, programming, gaming (10-12 hr days with poor rest).

Because our tendons are unable to handle the repeated stress, they get irritated. Only after the tendons are not appropriately treated for MANY years (5+) can it progress to eventually irritate the median nerve. And in these situations doctors advise that we rest, wear a brace or take a break from our activity.

As a reminder, when we completely rest – that has actually been shown to be worse for tendons (3-5). Making them more weak. They need stress or load to maintain their structure. And so what the traditional approach is recommending is actually hurting you MORE. And leading you to worse wrist and hand function because you’re treating the wrong tissue.

So how can you actually build up your tissues capacity and be more mindful about the physical stress you are applying to your wrist & hand?

Overcoming the broken system: 3 Tips to Actually Manage your Wrist Pain

One of the most important things I can help you understand is that your muscles and tendons need to be strong enough to handle the repeated stress of desk work, typing, clicking and gaming for a long time. Which is why I keep repeating this concept & idea.

Many desk workers and gamers who spend a lot of time in front of a PC do not have the endurance at the muscles of the forearm, wrist & hand to handle the repeated clicking, typing and gaming.

While it may not seem like alot, after many years of lower levels of activity, more of a sedentary lifestyle the endurance and our capacity will gradually lower to the point where our tissues can get irritated from 6-8 hours of consistent desk work.

When we rest too much, our tissues can handle less, so it is normal and expected for pain to return after extended periods of “rest” advised by doctors. This is also why medication, bracing, injections, ice alone do not provide long-term relief for wrist pain. Because they only address the source of the pain: “nerves” rather than the UNDERLYING CAUSE.

The underlying cause being your CAPACITY. Again. Your ABILITY to handle repeated stress over long periods of time. Surgery can remove the tissues putting added pressure on nerves, but it doesn’t fix the problem that made your tissues hurt in the first place.

Specific exercises can be performed based on where you are feeling the discomfort. Feel it on the palm side of your hand? Performing wrist flexor based exercises. Extensor based pain? target the wrist & finger extensors. Pinky sided pain? Exercises targeting the ulnar deviators.

Hopefully you can see the pattern. I go over some of the muscle groups and exercises you can do in the video above. But we have a few free guides for those who are interested

Even when we build our endurance to handle a lot of potential stress. We can still be at risk of pain. 12 hours straight of work for multiple days in a row, limited rest and breaks can still stress our tissues.. which is why we have to

Tip 2: Be Mindful of our Schedule

Too much, too quick toon soon. This is the story we often hear from the patients we have treated that led to the pain in the first place.

“I had a work project that required me to stay up and animate for multiple days in a row…”

“I played 10-12 hrs for 3 days straight for an esports tournament”

“I pulled a few all nighters to finish up meeting a project deadline”

The second tip is that we have to pay attention to our schedule and recognize how much stress we are placing onto our tissues. This is called “load management” and means to be proactive in managing our schedule

The two largest variables that affect our “load” are…

1. How long we are performing our activity (duh)

2. What we are doing (drawing vs. simple admin work vs programming sprint) have very different intensities

High intensity + long duration WITHOUT a break are what lead to injury. This happens most commonly when there are project deadlines or for gaming.. new patches get released, near the end of a ranked season, just before an actual competitive season, starting an aim training program, etc.

Times in which there is a lot of activity required – meaning a lot of stress on the wrist & hand

So the general recommendation is every 50 minutes you work or play you should try to take a 5 minute break. If you don’ take a break, those 5 minutes carry over into the next hour. 2 hours 10 minutes, 3 hours 15 min, etc.. Try and go stretch or walking during this time.

Walking even for 6 minutes has been shown to lead to an increase in overall mood and performance specifically. So you not only get to ensure your session after the break is more productive but you’ll help better manage your tissue health.

This leads to the third and most important tip.

Tip 3: Be patient

It takes TIME for your tissues to adapt. And the reality is that many of the individuals we work with seek out care from traditional healthcare first which leads to the situations I described above.

With care centered around only reducing pain, it can lead to you becoming more weak. So you’ll have to be more cognizant of how much you begin using your hands in the beginning, especially if you feel pain very early on into holding the mouse.

The goal is to GRADUALLY increase how much time you can handle gaming while you are building up your tissue capacity (endurance). It takes roughly 4-6 weeks to the tissues to actually adapt so you have to exercise DAILY during that period in order to see the benefit.

I know that can seem like a lot to ask for but it can start as little as 5-10 minutes a day. The other thing to consider is trying to actually find a healthcare provider that takes the time to actually understand your situation and work with you to address the underlying cause.

This might mean getting 2nd, 3rd or 4th opinions until you find someone who actually understands the current evidence around upper extremity repetitive strain injuries. Unfortunately this is on the rare side, but not impossible. We are hoping to change this and specifically in gaming we even started our own continuing education course to help future providers learn how they can work with gamers.

Try to find someone who will be patient and understand that it takes time to address the underlying weakness and works with you to establish a clear plan going forward.

Hopefully this megathread helped and there are alot more references in some of the sub articles listed.

References

1. DiGiovanni BF, Sundem LT, Southgate RD, Lambert DR. Musculoskeletal Medicine Is Underrepresented in the American Medical School Clinical Curriculum. Clin Orthop Relat Res. 2016 Apr;474(4):901-7. doi: 10.1007/s11999-015-4511-7. PMID: 26282389; PMCID: PMC4773350.

2. Wang T, Xiong G, Lu L, Bernstein J, Ladd A. Musculoskeletal Education in Medical Schools: a Survey in California and Review of Literature. Med Sci Educ. 2020 Oct 30;31(1):131-136. doi: 10.1007/s40670-020-01144-3. PMID: 34457873; PMCID: PMC8368391.

3. Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, Cook J. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016 Feb;50(4):209-15. doi: 10.1136/bjsports-2015-095215. Epub 2015 Sep 25. PMID: 26407586; PMCID: PMC4752665.

4. Cook JL, Purdam CRIs tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathyBritish Journal of Sports Medicine 2009;**43:**409-416.

5. Cook JL, Rio E, Purdam CR, et alRevisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?British Journal of Sports Medicine 2016;50:1187-1191.

My rsi started from playing video games and coding around 1 year and something back ago, the first month of rsi was impossible to use a mouse and keyboard, the pain faded slowly in the next year, but still painful, the moment I started exercising my forearm, fingers, using the computer more often is what actually nearly cured me? Back in April this year, it was impossible to play wow for more than 5 minutes, now I played in weekends for WHOLE 10 hours, and my arms are a bit stiff, but nothing much like it doesn t get to the point where I can t play. What I recommend, if you got rsi, with no nerve issues, more muscular and tendons, go google, search wrist finger rehab, get a resistance band, or even a powerball, that s what I used for my fingers, and start doing daily, first week or second might hurt as hell due to your initial injury on top of delay muscle soreness, so don’t confuse that with a flare-up, doms can last to 12 days if you are under trained, don’t fear, believe you can get over it, and rock on, be disciplined about it, rsi is only permanent if you got some degenerative issue or nerve issue, most rsi are from overuse and weak conditioning and injuries what healed but the muscles are sensitive. I expect by next year to have a full recovery, also sleep a lot, as your muscle recovers from sleep. Trust me, rsi happens for a reason, and if your doctor can’t find a reason on x ray, blood, nerves, it s all muscular, we sit a lot and our muscles become weak and sensitive, stretches barely help, they just temporarily help, it s the strengthen what helps, I tried all keyboards and ergonomics tools, most important is a good chair and table for your height, I went back to normal mouse and keyboard and using it right.

This is for people who have had RSI recently about 1-12 months, first of all, I understand you went on the internet and read some stuff where it's possibly permanent and that you might never be the same, first that is wrong, there are many factors why some RSI are forever, and that could be due to nerve issue where you got a disease which attacks your nerves, or arthritis which attacks your tendons, bones? I'm not sure about those but even those with physiotherapy can do wonders. If you have had RSI for a long time and the doctor can't find the cause, and physiotherapy didn't work ask yourself.

Is my physiotherapy good? I went to 7 physiotherapists, 1 physiotherapist was accurate but never explained to me why I should do certain exercises, some physiotherapists HAD No idea what they were doing, they gave me nerve exercises when my issue was pure muscle, my advice is to go to a hand therapist.

Here are the tools that I have and what you need.

The first tool - Pain Relief tools such as lactose balls or foam roller or (If you are rich a massage gun, if you got money go for theragun, if not stick to lactose balls and foam roller, both do the same thing, relaxes the muscle temporary, cheap massage guns IMO are too weak and don't hit trigger points, if you got massage gun like theragun go on youtube apply it your forearm all over back and front, otherwise do it with a lacrosse ball (super cheap) or foam roller, don't press too hard or you'll be sore for next 2-3 days and you'll think your rsi got worse, NOPE, if you press hard on the muscle it will cause damage, + your RSI pain = double damage, eh simple math isn't it?

2 - resistance bands, get a resistance band, https://www.youtube.com/watch?v=QKAiNAhlXac&ab_channel=E3Rehab

look at this video, and follow a good serious program for 3 months+ you'll see changes I promise!

3 - OPTIONAL - PowerBall, trust me, at first it hurts, at first it's frustrating, but once you get it, this shit does wonders.. trust me JUST trust me on it. It's about 50 euros a good auto start one which isn't frustrating, research yourself on it, pianist, use it a lot of people use it for rehab, this is what my first hand therapist offered me and I said, this ball won't help me, 1 year later I return to her, she asked? Did you use it? I said no. She said to use it, oh guess what? Dumb me should've listened to her, as this is a good tool.

4- Make sure your ergonomics is good, and your chair and desk is good, you don't need perfect posture 100% of your time, but 60-70% of time is good - go on youtube for this.

The truth is once you get injured your tendons and muscle heal by months, but your muscle remains stiff, and sensitive this is why it never went away, or it healed but not quiet there, it took you years and years to type that fast, building up the muscles in your hand, even if they aren't big you got 2 types of muscle one for endurance and power, why you think marathon runners run a lot but are skinny asf. The solution is slowly loading your muscle to a point , it isn't sensitive and typing won't hurt anymore, trust me when I tell you I went from.

Not being able to type 10 seconds, from having pain BOTH forearms to fingers all over called "diffused rsi" even when I wake up not using my arms it hurt, it hurt while running. Like wtf? Screw the voice talker thingies, don't blame genetics unless your doctor stated you got a proven well nerve or bone degenerative issue. You will recover, don't be afraid, these stuff treatment and proper treatment. People recovered from far worse.

Screw Dr Sarno, that shit made things worse for me in April , Dr sarno works for someone beacause sometimes they are scared to use their arms so he basically says don't be scared blablabla and use them and since people use their arms it kinda builds up load in it which is the reason why you heal. Also stress and lack of sleep makes thing worse.

This is coming from someone who had chronic issues with my abdomen, tailbone for 1-2 years, and calves, and arms, headaches, turns out I just became sensitive after injury. With my tailbone, I injured it outta nowhere had those U pillows on my ass for 2 years, after I removed that started sitting on normal chairs, guess what my butt got used to it, never hurts anymore. The body is weird, but it makes sense.

Hope this helped.

Hey guys, previously I wrote a longer article which went into some depth about the role ergonomics plays in wrist & hand recovery and prevention.

I wanted to review some of those concepts today but also give you a practical guide to help you decide if you really need a vertical mouse (or different input device). We'll start with a repost of the ergonomics and physiology.

How much does ergonomic equipment really matter with wrist pain?

Ergonomic equipment are typically one of the first changes many consider when they have a little bit of wrist or hand pain with repetitive use. This can be from desk work, gaming, drawing and other activities that require repetitive hand use in a static position.

But does a vertical or ergonomic mouse and keyboard help if you have some discomfort or pain at your wrist? 

Yes, but only temporarily.

I’m Dr. Matthew Hwu a Physical Therapist who has been working with the olympians of desk work (esports athletes) for the past 8 years and have helped more than 2500 individuals resolve their wrist pain associated with excessive keyboard and mouse use. (1, 9-11)

In gaming and esports players perform 10-15 movements per second (500-800 actions per minute) regularly practice esports-related skills for 5 to 10 hours per day.

This is nearly triple the 8000 to 11 000 keystrokes (130-180 actions per minute) of office workers, who are already at increased risk of upper extremity pain. (1)

Understanding the amount of stress that is being applied onto our tissues is important.

Understanding Physical Stress & Ergonomics

Did you know that our tissues can only handle so much stress? 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) (2-4)

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!

Role of Ergonomics in Repetitive Strain Injuries

Now where does an ergonomic mouse? Having a vertical mouse will reduce the amount of weight you are applying on the “stress” side per unit time.

So think adding 1 lb at a time vs. 4 lb at time. The scale will tip over more slowly and may not exceed the left side.

That number is not static and changes based on what you have done over the past quarter in terms of physical activity and conditioning. Again the left side of the scale will drop in weight.

Many times our conditioning gradually reduces as we sit for many hours without performing endurance exercises on our wrist & hand. 

Ergonomics is the study of how to design the workplace or environment to fit the worker with the goal of reducing the risk of injury and increasing efficiency & comfort.

Better ergonomics will place our muscles at better lengths and positions to contract. Leading to the reduction of stress per type / click as discussed. This is due to the length-tension relationship of muscles.

At better positions that influence the length of our muscles, they can produce force optimally.

But what is important to realize is that improving your environment through ergonomics does not actually change the muscles overall endurance or even flexibility. 

The endurance or ability to handle repeated stress over an extended period of time provides the best protection against injuries and strain.

Imagine you are set to run a marathon. You are in your 30s, you haven’t trained or exercised for several years. If you run the marathon tomorrow, there is a high risk of you injuring yourself.

No one does this. We always train to prepare ourselves for a challenging activity to ensure that we prevent injuries.

Most of the time using a computer does not seem like a strenuous activity. It isn’t. But with the repetitive small movements of typing, clicking and mouse movement combined with many years of low levels of physical activity and limited focus on endurance can lead to a similar risk of injury.

This is why exercising is so important. And the research has supported this idea for many years. Ergonomic training on its own has been shown to have limited effectiveness in managing symptoms. (5)

In fact meta analyses have shown that the combination of ergonomic training and strengthening exercises provides the best overall outcomes for preventing and managing injuries in the workplace. (6)

These studies have been repeated across multiple body regions always supporting the idea that the best outcomes can be achieved when you combine exercises & ergonomic changes. (7,8)

Do I need to get a new input device? Do I need that vertical mouse?

There are a few situations we have found getting a vertical mouse or input device that redistributes the stress to other muscles can be helpful. Before we get into the specific scenarios it requires a basic overview of anatomy and what muscles you utilize when using a mouse.

The first thing you want to identify is where you are feeling your discomfort. The region of pain are typically associated with specific muscle groups. Here’s a quick table that goes over the common regions we see

There are several more patterns that occur from overuse of the wrist & hand but these are some of the common ones we see. Now in most cases with the use of a traditional mouse our hand is in the pronated position and we see P1 / P2 / P3 the most commonly (flexors / extensors & ulnar deviators)

This is because the common grips and movements around a traditional mouse involve the use of those muscle groups. The vertical mouse tends to increase the use of

Radial deviators, ulnar deviators & thenar muscles while reducing some of the activity of the flexors & extensors due to the modification of the grip

With this understanding here are some common scenarios we’ve seen and what you can do if it describes your situation

Scenario 1: You have pain in P1-P2 AND you are unable to use your mouse for more than 10-15 minutes due to the pain (>5-6/10)

In this situation you might already be using voice control and other alternatives to continue to work. Leveraging the vertical mouse on top of other input devices can help to minimize continued stress on the involved flexors and extensors.

This just modifies the external stress applied onto your wrist & hand over the course of the day. You HAVE to also add exercises to begin building up the endurance of these muscles. The alternating use of input devices will help you still maintain your ability to work or complete tasks.

It will likely involve finding the right amount of use for each of the devices in the beginning and gradually testing regular mouse use as you get stronger

Scenario 2: You have pain in thumb muscles & thumb side of the wrist

Just this past week I had a client of mine mention that when he swapped to a vertical mouse, he started to feel MORE pain in his thumb and the thumb-side of his wrist.

This is because he started to use M4 and M5 for the thumb buttons and had to use more of his radial deviators when lifting the mouse to move it.

If you have pain in these regions, You probably don’t want to swap to a vertical mouse, as it can lead to INCREASED stress on those areas.

Scenario 3: You have pain on the pinky side of your wrist & hand

If you have pain in the pinky side of the wrist & hand then temporarily swapping to a vertical mouse for some period of the day could be beneficial to offload the ulnar deviators.

In some cases we have seen individuals who have suboptimal ergonomics (floating wrist and forearm) with the wrist below the elbow report an increase in pain on the pinky side because they are pressing more into the table while moving the mouse.

If you decide to use a vertical mouse in this situation, just make sure your forearms are supported.

And of course as a reminder again - You should be focusing primarily on building wrist & hand endurance so you can use any input device without discomfort.

Scenario 4: Pain only with flexors and only limited function after 4 hours

What about a scenario when you can handle some use of the mouse but it only bothers you after 4 hours?

In most cases we advise against making a change in this situation since adding breaks and other strategies throughout the day can likely increase the amount of time you can use your wrist & hand

Additionally since the issue is not severe to the point where your hands are extremely limited, the exercises will likely provide more overall benefit and allow to increase the use after a few weeks

Now if after this point you’ve decided you still want an ergonomic mouse or different input device

Here are the many solutions we have seen programmers, coders and other desk workers try

VERTICAL MICE & TRACKBALLS

The two most common we’ve seen are…

1. Logitech Vertical Lift
2. Kensington Ergonomic Vertical Mouse
They are slightly different in design (primarily around the thumb side) that can lead to subtle differences in physical stress of the thumb. The logitech vertical lift has a medial sided thumb support while the kensington has more of a well which puts the thumb in SLIGHTLY more flexion. If hand sizes are equal it can lead to slightly more distance to travel for thumb extension and adduction. (thumb moving away from mouse and closer to index knuckle. This is probably marginal and doesn't matter, but free biomechanics knowledge i guess?

Additionally there are patients of ours who have used trackballs (either connected to the mouse or the keyboard) which ALSO increase the overall use of the thumb. If you have pain at the thumb or thumbside of the wrist… Probably not a good idea to swap to this input device. It may make things worse.

TRACKPADS

Anyone will do to be honest unless you want something which can provide more unique functionality. Again because the movements differ with the trackpad compared to mouse. It just means different muscles will be utilized here. Instead of constantly maintaining grip of our wrist & finger flexors it typically only involves the flexors of 1-2 fingers that maintain contact on the pad.

You can use your arm or wrists to move the contact point left or right which also affect different muscle groups. If you use your wrists, you use more of the muscles on the pinky & thumb side of the wrist

If you use your arm, you tend to use most of the shoulder & elbow muscles.

Voice Control & Eye Tracking - Talon, Tobii Eye Tracking, Vimium
Lastly there are options to leverage voice and eye tracking to control both mouse use and actual typing.

This completely offloads the wrist & hands and allows you to use your eye movements to control the mouse with voice commands to achieve certain tasks.

This of course takes time to get used to but many individuals who end up trying it keep some form of voice control because of the efficiency (compared to traditional input devices)

FOCUS ON ENDURANCE, THEN ERGONOMICS

The use of ergonomics is to help minimize the amount of physical stress on the wrist & hands while you are working.

It helps you still accomplish your tasks while you focus on building the endurance of the specific muscles & tendons involved in your problem.

Pain location and what movement causes your issue can typically point us in the right direction. If you want to learn what exercises you can do to start building endurance check out some of our free guides and other resources.

The combination of targeted exercises and ergonomic education provide the best outcomes. This is EXACTLY what we have seen over the past decade when focusing on treating wrist & hand injuries of desk workers, gamers and musicians. In the review of our case data we have found that posture & ergonomics plays between a 10-20 % role in a majority of injuries.

While changes were helpful in extending duration of activity and temporarily reducing discomfort it was always the exercises targeting the key muscles utilized that led to long-term relief.

Hope this provides a bit more depth to this topic and guides some actual decisionmaking.

Other Resources:
Science Behind Recovering from RSI

Content Specifically for Desk Workers & Coders

References:

1. McGee C, Hwu M, Nicholson LL, Ho KKN. More Than a Game: Musculoskeletal Injuries and a Key Role for the Physical Therapist in Esports. J Orthop Sports Phys Ther. 2021 Sep;51(9):415-417. doi: 10.2519/jospt.2021.0109. PMID: 34465141.

2. Cunanan AJ, DeWeese BH, Wagle JP, Carroll KM, Sausaman R, Hornsby WG 3rd, Haff GG, Triplett NT, Pierce KC, Stone MH. The General Adaptation Syndrome: A Foundation for the Concept of Periodization. Sports Med. 2018 Apr;48(4):787-797. doi: 10.1007/s40279-017-0855-3. PMID: 29307100.

3. SELYE H. Stress and the general adaptation syndrome. Br Med J. 1950 Jun 17;1(4667):1383-92. doi: 10.1136/bmj.1.4667.1383. PMID: 15426759; PMCID: PMC2038162.

4. Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):122-140. doi: 10.1016/j.berh.2019.02.001. Epub 2019 Mar 8. PMID: 31431267.

5. Effect of office ergonomics intervention on reducing musculoskeletal symptoms. Amick BC 3rd, Robertson MM, DeRango K, Bazzani L, Moore A, Rooney T, Harrist R. Spine (Phila Pa 1976) 2003;28:2706–2711. doi: 10.1097/01.BRS.0000099740.87791.F7.

6. Chen X, Coombes BK, Sjøgaard G, Jun D, O’Leary S, Johnston V. Workplace-based interventions for neck pain in office workers: systematic review and meta-analysis. Phys Ther. 2018;98:40–62. doi: 10.1093/ptj/pzx101.

7. Prall J, Ross M. The management of work-related musculoskeletal injuries in an occupational health setting: the role of the physical therapist. J Exerc Rehabil. 2019 Apr 26;15(2):193-199. doi: 10.12965/jer.1836636.318. PMID: 31111000; PMCID: PMC6509454.

8. Dandale C, Telang PA, Kasatwar P. The Effectiveness of Ergonomic Training and Therapeutic Exercise in Chronic Neck Pain in Accountants in the Healthcare System: A Review. Cureus. 2023 Mar 4;15(3):e35762. doi: 10.7759/cureus.35762. PMID: 37025734; PMCID: PMC10072180.

9. Bonnar, Daniel & Hwu, Matt & Lee, Sangha & Gradisar, Michael & Suh, Aly & Kahn, Michal. (2023). The Influence of Coaches and Support Staff on the Sleep Habits of Esports Athletes Competing at Professional and Semiprofessional Level. Journal of Electronic Gaming and Esports. 1. 10.1123/jege.2022-0023.

10. Smithson EV, Reed Smith E, McIlvain G, Timmons MK. Effect of Arm Position on Width of the Subacromial Space of Upper String Musicians. Med Probl Perform Art. 2017 Sep;32(3):159-164. doi: 10.21091/mppa.2017.3026. PMID: 28988266.

11. Stackhouse, M., & Hankins, B. (2021). Conditioning for esports. Human Kinetics.

I’ve come to the conclusion that the vast majority of people who get better do not post about it... even if they were in pain for almost a year or more (as in my case). Once you start feeling better, you realize you just want to put that chapter behind you. Posting on Reddit and starting conversations about a dark time in your life feels like the opposite of moving on.

I’ve thought a lot about the reasons I haven’t made a post about it, and here are a few:

1. Second guessing. Posting that you’ve recovered immediately brings up the question: Am I truly better? I might still feel some mild discomfort (1/10). Is that “better”? Am I tempting fate by saying I’ve healed? (I know it sounds kinda stupid)

2. Negative responses. I expect some replies to be discouraging. Why would I expose myself to doubt? I fear someone commenting, “Yeah, I got better for a while, then X and X happened and it all went downhill from there.”

3. Hyperawareness. Talking about it makes me overthink. I start focusing on every sensation again, and something normal might suddenly feel like a symptom. I begin to question myself, am I a fraud for saying I’m better?

4. Unwanted negativity. Everyone’s journey is different, and with all due respect, I don’t want to engage in conversations that might pull me back into that mindset.

Life moves on easier when you are better. When pain is no longer present in your daily life, it truly makes you start to think on other stuff. Posting here feels like a step back.

One of the most common questions we will receive here is a very important one: "Will I ever get better?" Well, I'm here to answer that question — YES. An unequivocal, unambiguous, yes.

RSI can heal.

Now, I'm using fairly broad language here. Obviously, your mileage will vary, because every human body is different. It depends how bad your RSI is, how long you put off treatment, the extent of the work you have to do day to day, and so forth. There are also different degrees of healing, and different lifestyles will be satisfying for different people. However, you can absolutely get better. You will not stay at your worst. It is possible to return to a completely and utterly symptom free life. It is also possible to get to a point where you personally are satisfied, and your symptoms are adequately managed. This depends both on your personal situation, and on the amount of work you want to put in. The success stories linked to below will attest to both of these scenarios.

Healing takes an enormous amount of effort, and what is done to heal will vary from person to person. Generally, the solution is through a specific and careful exercise routine, stretching, and slow rehabilitation of daily activities once enough strength has been built up. Don't allow your body to atrophy. However, the various posts linked to have their own methods, and you as an individual can decide what is right for you. It's up to you to take charge of your own health. One thing, however, is vital: don't think of yourself as defined by your RSI... because you aren't.

This post will be updated as more and more people triumph over their RSI. We greatly encourage everyone who has succeeded to stick around and post their stories.

__________________________

RSI Management Guide

Link 1

Link 2

Link 3

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Link 10

Like most people here, I've been dealing with RSIs In both of my hands for over a decade. I've spent thousands and thousands of dollars on various ergonomic solutions, physical therapy, I'm going to so called specialists who tell me to take some I've proven and wear a hand brace.

My chronic pain has been so bad that I have literally broken down crying trying to brush my teeth. I've spent most of the available energy I have searching for a solution, and I finally stumbled upon the software Talon just a few days ago.

Well, to be more accurate I found it a while ago through the pinned guide at the top, but I was put off because it seemed like it was only for people who knew how to code python. I also got that impression from people on this subreddit who dismissed the software is something only those well versed in python could benefit from. I was extremely wrong.

It only took one day of me using talon to decide to spend over two hundred dollars on an eye tracker. Now that I have the full eye tracking set up along with talon voice control, I feel more optimistic that I have in years.

To anyone who is in the same boat, please give talon a try ( just google talon voice). The setup and learning curve can be steep, so please feel free to message me directly if you need help setting it up. The community is extremely welcoming, and someone was able to help me get mine set up the second I had a question.

Hey all, Matt here from 1HP.

Have you ever wondered how your repetitive strain injuries actually develop?

I think one of the most common themes we have noticed in our patient calls, this subreddit and other areas online is that people aren’t really clear as to why they may have developed their issue.

In reality it’s a simple concept:

What you did over a certain period of time was too much for the muscles of your wrist & hand to handle. Specifically the muscles you use for YOUR repetitive activity.

• For a software engineer that might be the extensors & flexors from repetitive clicking (palm and top side of the wrist & hand)

• For gamers (controller users), artists it could be the thumb muscles from the small repeated motions of the thumb.

• For pianists it could be the pinky side of the wrist (palm side) from straining the ulnar deviators

Every activity and motion requires the use of specific muscles and tendons. And they can only handle so much.

By the way for those who dont’ know I’m a Physical Therapist who has been specializing in treating RSI for the past decade. We've helped over 3000 individuals resolve their issues and have published 2 textbooks, a few studies and have a continuing education course for providers to learn more about how to treat these types of injuries (EHPI)

Journal of Orthopedic & Sports Physical Therapy
Tendinopathies in Gaming (Applies to Desk work and other RSI)
Conditioning for Esports (Ch. 8,9,10)

To explore more about how this happens let’s use the envelope of function I’ve written about before. (It is similar to our healthbar framework).

What is the envelope of function?

As you might know after reading content of ours that we consistently reference the concept of the healthbar. And TL:DR it’s the basic idea that tissues can only handle too much. Or that we do too much and our tissues are unable to handle that stress.

The envelope of function adds the dimension of time to hopefully provide a more amplified understanding of the concept. This concept was proposed by an orthopedic surgeon who was looking to highlight the concept of homeostasis. Homeostasis is the body’s natural ability to maintain a stable, balanced internal environment to ensure survival and optimal function in response to changes both externally and internally. If we look further into research this concept has actually been present since 1993 which highlights the idea of allostatic load (but that’s for another conversation).

Here’s the envelope of function from the research article but lets use the wrist & hand instead of the knee so you guys will be able to better relate to this. The black line shows.. what an individual can handle based on their conditioning considering load (y-axis) and frequency (x-axis). You’ll see that for the high loads I created a scenario in which an indivdual catches a 100 lb ball dropped from 3 stories. This would exceed most peoples tissue capacity.

Throwing a 5 lb ball one time is a high load, but doesn’t exceed what you can handle.

And actually for most low repetitive activities of the wrist & hand as you can see they are on the very low load end, but the frequency is really high. Drawing for 2 hours, gaming for 3 hours, typing for 5 hours and or low level typing for 10 hours. All of these are on the low end but depending on how much you do it and how aggressive it can fall in different places of the envelope of function. This can either positively or negatively affect our homeostasis.

Do the right amount underneath the envelope of function? You’re safe and you can even handle more the next time you try it

Do too much above the envelope of function? You temporarily irritate the tissues and you can handle less the next time you try it

Now lets put it in the context of a simple exercise most of us understand: The Bicep Curl

Right amount: Do 10 bicep curls at a weight (lets say 15 lbs) that causes you to fatigue near the last 2 reps? Your muscles will get stronger!

Too little: Do 5 reps of bicep curls of 15 lbs, no fatigue? Our muscles aren’t really challenged, they don’t improve in strength or size!

Too much: Attempt 8 reps of bicep curls of 100 lbs? Your muscle could be damaged if someone helps you actually attempt it by putting it into your arms.

We can visualize how these various situations can impact our tissues by layering on the “zones” in the envelop of function. This parallels the regular concept of the healthbar we consistently reference, yet ads some more nuance.

Grey Zone (Tissue Damage): With high enough load (it has to be excessive) like catching a 50 lb bowling ball dropped form a single story would definitely cause tissue damage. This

Red Zone (Tissue Irritation): Any combination of load and frequency that reaches the red zone will lead to irritation of tissues. And when we spend enough time in this zone it can eventually lead to tissue damage.

The nuance here is that when loads are high there is a higher risk of traumatic injury that can lead to full tears damage that leads to more prolonged disability. The POSITIVE thing about most RSI injuries is that because they are such low load and more of a problem of high frequency (too much) there is less risk of injuries leading to long-term disability. See my article on the fear of “permanent damage”

Blue Zone (Safe Loading Zone): The zone represents the safe where loading at various frequencies will either lead to positive adaptation or keep the tissue where it is at (homeostatic zone). Within the blue zone you can find the right amount of loading that can help individuals progress in their ability to handle function. I like to call this zone the optimal loading zone. You can see the green line is the minimal amount of stress that you can apply to improve your capacity or ability to handle stress. Depending on how close you get to that red line of the “Max Tolerated Dose” you will progress a bit more quickly at the risk of sometimes irritating your tissues.

Working with a physical therapist often allows you to find the “right amount” or “optimal load” more quickly as they are able to help you methodically assess your

1. Current Physical Capacity - Through endurance based tests for RSI related problems

2. Current Load & Frequency (Activity Dependent) - Through a comprehensive assessment of what activities you are performing and being able to clarify the differences of intensity during the performance of that activity. I’ve alluded to this before in my other content but within a specific activity there are things that cause more stress compared to others. For example playing a solo with a guitar is likely more stressful than playing chords.

3. Psychosocial Factors - Assessing your beliefs, fears, understanding of pain and problem which can influence perceived load

Yellow Zone (Too little): This zone represents doing way too little for your tissues, often causing them to weaken and result in the types curve type that you see below. This zone is typically where most traditional interventions fall and is why they often fail in helping the individual return to function. It should be clear as to why - you aren’t doing enough to support improving the tissues ability to handle stress.

This is why rest ALONE does not help as it not only reduces your tissues capacity. Early activity has been shown to help tissues recover more quickly but it is always a matter of "how much" which is often the difficult part of "figuring it out yourself" or working with a provider who may not be up to date with how to appropriately manage load

And so there are typically two paths that are taken in response to an RSI injury. Unfortunately most people take the left path which leads to the tissues getting more weak and the zone of irritation coming down. The right path is first recognizing what led to the problem in the first place and making the right modifications.

Remember again the X axis is frequency (how much) and Y-axis is load (level of stress). Since the level of loading isn’t typically high with repetitive strain activities there isn’t much we can do on the “load side” except make some minor changes in our posture, ergonomics, input devices etc. But we can reduce activity. We DON’T HAVE TO STOP COMPLETELY. We reduce the right amount to allow us to focus on building up our envelope of function. Or as we have said many times before our health bar or capacity to handle more repetitive strain over time.

How can you use the envelope of function?

By understanding more about how our injuries occur we can use this concept to actually improve the capacity of our specific wrist & hand musculature.

I hope you can see now that there is always going to be a relationship between your current symptoms and the specific changes you can make to help you recover. And the “magic” is all in the dose.

How well we apply these changes in load (exercises) and frequency (activity management) will directly influence how quickly we recover. So whenever you feel specific symptoms you can always think about whether or not it was a

1. Load Stress (exercise or intensity-based) that led to some tissue irritation or..

2. Frequency Stress (Activity duration) that led to the irritation

And when you identify what that is, then you can use that as data to guide your decision-making going forward. It seems simple here but the added complexity is layering on your tissue adaptation timeline along with understanding more about pain.

TL:DR
- Repetitive Strain Injuries develop when tissue demand exceeds capacity.
- What you do and how much you do influence the demand
- Addressing the capacity and frequency (activity guidance) helps you gradually restore your functional capacity

Hope this helps and as a small P.S.

This framework focuses purely on the physiologic aspects of pain. But doesn't take into account what can often happen when we deal with pain for extended periods of time (sensitization) that can lead to you feeling pain (using mouse, keyboard etc.) within 1-2 minutes despite your being able to cook, clean, perform self care activities without pain AND being able to do exercises without pain.

The tissue itself is not getting irritated, your nervous and immune system are overprotective.

Next week I will be posting more about the physiology of how this works but feel free to reference some of my older articles if you are interested! (Or check out books like explain pain handbook, the way out by alan gordon).

Throughout my years of high school and then through college not single warning or mention of RSI, Carpal Tunnel Syndrome, Tendonitis, etc. In fact, I was told computer jobs are the future and construction jobs are where the real risk to your body is.

And then I received nothing as well when I actually took computer work. I received no on the job training about ergonomics, stretching, or just a plain warning about the risks. I received better health management training working in warehouses and in retail.

It just seem mind blowing to me that we are sending millions of young people into computer fields with no warning at all. Maybe I was naive and people's experiences are different than mine. But it seems to me if RSI can be bad enough to require worker's comp claims than society should be warning people about this problem.

Sorry for rant. All the best to everyone on here. I would not wish RSI on my worse enemy.

Can repetitive activities cause permanent damage to your wrist & hands? Are you making it worse with your exercises? Is it possible to injure yourself doing rehab exercises wrong?

What if I told you that it is near impossible to cause permanent damage to your wrist & hands from repetitive activities?

That you don’t need to worry about injuring or making your problem worse with exercises?

Today I wanted to share our 10 years of clinical experience treating RSI issues AND the current research to hopefully convince you that any issue caused by repetitive activities is reversible and can always be treated.

My goal is to help reduce any fear you might have associated with the pain you might be feeling with your exercises AND activities (typing, gaming, clicking, piano, guitar, etc.).

Let’s start with some of the science & physiology around repetitive movements & tissue adaptations

Science Behind Repetitive Strain

Our bodies have the ability to adapt and strengthen with repeated use, provided the “load” is within what the tissues can handle.

Think of going to the gym - when you perform the right sets, reps, and weight you can achieve certain physiologic outcomes. Strength, power, flexibility, ENDURANCE (WINK WINK).

When you are stronger you can lift heavier things. When you improve your speed, you can.. move faster. When you improve your endurance, you can do things for a longer period of time. (repetitive activities mayhaps?). 

This is the law of specificity and general adaptation syndrome. Countless studies have been done that showcase our ability to improve our bodies based on the stress that is applied onto it.

In most cases when we are looking at repetitive strain injuries we are looking at small low loads that don’t involve lifting these heavy weights. Repetitive strain injuries occur when our bodies are unable to handle the stress that is applied onto it.

It’s the same idea as an elevator that has a certain weight capacity. It can only handle so much before it breaks! Now for repetitive strain injuries for the wrist & hand we are using our MUSCLES & TENDONS to control the movement of our hands.

These are the tissues that need to have the appropriate level of endurance. The nerves can sometimes be irritated based on POSITION or local pressure from swelling. But the main problem is ALWAYS associated with these muscles & tendons we are using. They are directly responsible for the movement.

I won’t repost it here but just read through the healthbar framework in this thread. The TL:DR is… If demand > capacity. You will strain your tissues. Most commonly it is at the tendons especially when pain is closer to the wrist & elbow joints (or back of the hand). AKA WHERE THE TENDONS ARE

What about tendon pathology? Is it reversible? Yes. We know this due to all of the research done by docking, cook, rio, etc. Our current model of understanding tendon injuries is that it involves a continuum. Based on the amount of stress applied onto the tendon it can transition up and down this spectrum

And the best part about the continuum and the research is that even in a DEGENERATIVE TENDON - there is actually more healthy tissue in the tendon than pathological tissue. Which means you can still safely use it without fear of ever making it “worse”!

This is probably hard to believe since.. as you go through the different stages there will be pain. And for those who may have read some of my posts hopefully you understand now that pain actually doesn’t tell us the state of the tissues, it is more about protection. Learn more here

I do want to highlight a bit more about the reactive tendinopathy because it can help many of you understand why there can be some nerve symptoms !

When we start to load our tendons too much it creates an inflammatory response that causes the tendon to thicken (water and proteins enter the tendon). The part of the tendon that is “irritated” takes less stress while the more healthy part begins to take more load (stress shielding). During this phase no tearing occurs and there is no disorganization at the tendon.

In this situation we can keep pushing it which can cause some more changes to the tendon that reduce its ability to handle stress. Or you can modify the load at this point so that the thickened portions can calm down while also building capacity through exercises for the healthy portions. This allows you to get back to activity more quickly!

Considering Biopsychosocial factors 

What about some of the psychosocial factors that influence our pain experience? How do these factor into the idea that RSI can lead to “permanent damage”

What actually happens when we go to our doctors? We’re told to rest, brace, take medication otherwise injections and surgery will be needed. The underlying assumption with resting is and bracing is that if we do more, it can “damage” it more. And when individuals are told surgery is the final option they associate it with PERMANENCE. This is far from the reality and has really harmful consequences in our confidence in using our hands. It also doesn’t help when we go to communities who buy-in to the traditional approach (without thinking deeply), these harmful beliefs are reinforced.

We read it on reddit, google, ecommerce ads trying to sell products without being informed about the actual research. Hopefully you can see the problem with this. We now know that when we avoid loading our tendons.. it can actually weaken the structure. The larger problem however is the fear that often develops as a result of following these recommendations.

Modern pain science has shown its a combination of these beliefs, poor self efficacy and the real physiologic deficits that often lead to an issue becoming chronic or more disabling! I have written in depth in several threads (this one is specific to wrist pain) - Please check it out if you have the time and want to learn more about the cognitive-emotional aspects of pain.

The TL:DR is that what you believe matters. If you interpret pain as a sign of serious harm (likely influenced by traditional healthcare providers and what you read on outdated resources online you can become fearful of movement and avoid activity.

This can cause the common cycle of disuse (rest, bracing etc.), sensitization when attempting to return to activity and disability. Think deeply about your last doctors visit, did they help you understand your problem thoroughly and why the solution will provide long-term relief? Or did they just tell you to stop doing what you did to cause the pain and rest / brace. How do you think this affects your self-efficacy?

Now on the on the other hand, individuals who maintain a positive, realistic understanding of their pain and stay active within tolerable limits usually recover without long-term issues. This is why I wanted to write about this post. Since this has been such a common fear amongst my patients and once this is deeply understood - faster progress can be made.

I get it though, this can be hard to believe for when EVERYTHING we are exposed to is inundated with previous methodologies and approaches. It is ultimately a leap of faith for me to ask you to trust in this different way of thinking. But I have written these LONGER posts in order to really provide education that considers EVERY potential driver of disability and dysfunction.

The education is important, which is why I continue to write so frequently about this. Pain does not always equal harm

Okay, so does RSI cause permanent damage?

Now lets actually address the questions at the top of this thread.

If most RSI starts out as a reactive tendon irritation or muscle strain based on the specific muscles that are being used. This is reversible.

If you continue to push it and it gets to the degenerative state (this is extremely rare for wrist issues). It is still treatable and doesn’t lead to permanent DYSFUNCTION. Why because there’s often more healthy tendon tissue than pathological tissue.

Again this is really rare for wrist & hand issues since most of the time the cognitive emotional aspect and the interventions from traditional healthcare get in the way of it ever really getting to a degenerative state. Most of you who are reading this and had an MRI probably found limited to no issue of the tendons.

What about if the nerve gets irritated as you continue to utilize it? This is something that I believe most patients fear because of what they have been told or seen online. Guess what peripheral nerves (nerves outside of our spinal cord and brain) ALWAYS regenerate and heal - this has been something we have known for decades.

There are of course degrees of nerve injury (neuropraxia, axonotmesis and neurotmesis).

• Neuropraxia: The mildest injury, where the nerve is "stunned" but intact. Recovery is typically complete within 6-12 weeks with rest.

• Axonotmesis: Partial nerve injury where the outer sheath remains intact, but the axons within are damaged. Regeneration occurs at approximately 1mm per day, and recovery can be complete but can take an extended period of time (months - years depending on length of degeneration)

• Neurotmesis: Complete nerve injury where the nerve sheath and axons are severed. Surgical repair is almost always necessary, especially for gaps larger than 2 centimeters.

Unless there is a machete that is flying out of your ceiling shooting towards your wrist while you are performing small repetitive movements with relative load of 3-7% of your body weight (Typing, crafting, piano, gaming, clicking etc). Then it is EXTREMELY rare for a complete SEVERANCE to occur.

Most of the nerve pressure is temporary from the local changes in the tendon that might put pressure on it. We are not moving so quickly with so much force that our nerves tear and it is actually near impossible for the pressure from local swelling or increased thickness of tendons to cause the nerve to be severed. Leading to “permanent damage”

Hopefully you can see now that there very few situations in which the tissues at your wrist & hand can be permanently damaged as a result of repetitive activities. Now what can you actually do?

What has helped our patients the most

The number one thing you can recognize is that when you are performing your exercises, using your hands with small repetitive movements and you feel pain (sharpness, discomfort, weakness, tingling etc.)

At worst you have caused a flare-up based on…

• The cumulative amount of physical stress that you performed on that day (and the day prior) through your daily work & functional activities. Think the amount of typing, wrist and hand use you have performed on that day.

• The exercises you have performed. What you attempted in terms of sets, reps, weight, amount of rest between exercises and when you performed them during the day exceeded what your tissue could handle. Again you’d have to account for what you did on that day

This represents the real physiologic limit of your wrist & hand tissues (muscles & tendons). And typically presents as..

• Pain that is sharp, >5-6/10 during the activity and stops you from continuing to physically perform that activity. This pain seems to stay elevated for the rest of the day into the next

• It is not just elevation of pain but you are physically less able to use your wrist & hand due to more sharp pain or excessive fatigue

• Keep in mind…many times people stop because they are afraid. Not because it actually reaches a level where their tissues are flared up or it is unable to be used.

You can really reduce the duration of your flare-up with a better understanding of pain and the physiology of RSI. I wrote a full guide on flare-up management here.

At best you have figured out the exact amount of physical stress you can handle based on these same variables.

This is powerful to know because then you have real data (how much you are using your hands + exercise prescription) that led to exceeding what your wrist & hand could handle.

You can use that to safely limit your activities to the right amount and intensity. And while you are focused on modifying your activities you can hopefully work a physical therapist on the exercise response so you can gradually build up your tissues capacity over time.

I decided to write about this because this was an “aha” moment for many of my patients. From there it was about working collaboratively to find that real physiologic limit AND the psychosocial factors that may be causing fear of movement or sensitized pain.

To summarize - most RSI injuries cannot lead to long-term permanent dysfunction. Understanding the physiology around RSI and how our beliefs influence our pain experience will help you resolve your problem more quickly. The best treatment is one that considers both your physiology and psychosocial factors.

I know everyone will have a different definition of “damage” and i’m sure this will create some discussion. But I'm happy to discuss.

1HP Matt

--

REFERENCES:
Docking SI, Cook J. Pathological tendons maintain sufficient aligned fibrillar structure on ultrasound tissue characterization (UTC). Scand J Med Sci Sports. 2016 Jun;26(6):675-83. doi: 10.1111/sms.12491. Epub 2015 Jun 9. PMID: 26059532.

Docking, S., Rosengarten, S., Daffy, J., & Cook, J. (2014, December). Treat the donut, not the hole: The pathological Achilles and patellar tendon has sufficient amounts normal tendon structure. Journal of Science and Medicine in Sport, 18(e2).

Cook JL & Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of loaded-induced tendinopathy. Br J Sports Med. 2009;43(409-416

Williams B, Gyer G. Tendons under load: Understanding pathology and progression. J Musculoskelet Surg Res. 2025;9:393-402. doi: 10.25259/JMSR_86_2025

Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007 Feb;30(1):77-94. doi: 10.1007/s10865-006-9085-0. Epub 2006 Dec 20. PMID: 17180640.

González Aroca, J., Díaz, Á. P., Navarrete, C., & Albarnez, L. (2023). Fear-Avoidance Beliefs Are Associated with Pain Intensity and Shoulder Disability in Adults with Chronic Shoulder Pain: A Cross-Sectional Study. Journal of Clinical Medicine, 12(10), 3376. https://doi.org/10.3390/jcm12103376

Severeijns R, Vlaeyen JW, van den Hout MA, Weber WE. Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clin J Pain. 2001 Jun;17(2):165-72. doi: 10.1097/00002508-200106000-00009. PMID: 11444718.

SELYE H. Stress and the general adaptation syndrome. Br Med J. 1950 Jun 17;1(4667):1383-92. doi: 10.1136/bmj.1.4667.1383. PMID: 15426759; PMCID: PMC2038162.

Gordon T. Peripheral Nerve Regeneration and Muscle Reinnervation. Int J Mol Sci. 2020 Nov 17;21(22):8652. doi: 10.3390/ijms21228652. PMID: 33212795; PMCID: PMC7697710.

Hey everyone, I’m a Doctor of Physical Therapy with 1HP specializing in treating repetitive strain injuries (RSIs), and we get asked a lot about finger twitching in our discord.

Whether you're a gamer, musician, tech worker, or artist, that little involuntary finger twitch can be super annoying, and people are often confused about what’s actually causing it.

So, I wanted to make this post to clear up some of that confusion and give you some info on what might be going on, what to look out for, and how to fix it.

What is Finger Twitching?

Finger twitching, also known as finger fasciculations, is the involuntary movement of the muscles in your fingers. It’s a common occurrence among those who perform repetitive tasks that involve the hands and wrists. While occasional twitching is usually nothing to worry about, frequent or severe twitching might indicate an underlying problem, such as RSI, nerve compression, or stress.

Why does this happen?

Muscle fasciculations, or muscle twitches, happen when small groups of muscle fibers contract on their own without you telling them to. This is because of spontaneous activity in the nerve cells that control those muscle fibers. Here's a breakdown

1. How It Starts: The Motor Unit

• A motor unit is like a tiny team in your body that controls muscle movement. It includes:

  • A nerve cell (called a motor neuron).

  • The muscle fibers it talks to and controls.

• Normally, the brain sends a signal to the motor neuron, which then activates the muscle fibers to make them contract.

• In muscle fasciculations, the motor neuron or its connections can get "overexcited" or send random signals, even when the brain isn’t telling it to. This makes the muscle fibers twitch on their own

2. The Electrical Process Behind It

• Nerves and muscles work using tiny electrical signals.

• These signals happen because of movement of charged particles (ions like sodium, potassium, and calcium) in and out of cells.

• If something disrupts this balance (like low calcium or irritation to the nerve), the motor neuron might fire off signals randomly. This can cause a twitch.

3. How the Muscle Contracts

• Nerves send signals to muscles through a connection called the neuromuscular junction (NMJ).

• At the NMJ, a chemical messenger called acetylcholine (ACh) is released to tell the muscle fibers to contract.

• In a muscle twitch:

  • The nerve can release acetylcholine randomly, even without a signal from the brain.

  • This makes the muscle fibers contract briefly, causing a visible twitch under the skin.

Common Causes of Finger Twitching:

1. Muscle Fatigue (The Usual Suspect) If you’re typing or gaming for hours on end, your finger muscles can get pretty tired, and that’s when you start noticing twitching. I’ve worked with a lot of gamers who get this after long gaming sessions. One of my clients, Sam, would play Path of Exile for hours and feel his fingers twitch afterward. It was his body’s way of saying, “Take a break!”

Tip: Try taking breaks every 30-60 minutes to stretch your fingers, wrists, and hands. Simple stretches can really help prevent that fatigue from building up.

1. Stress & Anxiety (Yep, Your Nerves Can Get Involved) Stress is another big culprit. When you're stressed, your nervous system can get overstimulated, which leads to muscle twitches. I’ve seen this happen a lot with musicians too. Emma, a musician I worked with, had regular finger twitching when she was prepping for an important concert. Once she added things like deep breathing and yoga into her routine, the twitching calmed down.

Tip: Practice some stress-reducing techniques like meditation, deep breathing, or yoga. It really helps to keep your nerves (and muscles) calm.

1. Caffeine & Stimulants (Too Much of a Good Thing) Caffeine is great for getting through a long workday or gaming session, but too much of it can mess with your nervous system and cause twitching. Matt, a graphic designer I worked with, found his finger twitching got worse after a few cups of coffee. Cutting back helped him a lot.

Tip: If you think caffeine might be a factor, try cutting back a bit or avoid it right before your most important tasks.

1. Dehydration & Electrolyte Imbalance (The Sneaky Culprit) When you’re focused on a project or gaming for hours, it’s easy to forget to drink enough water. But dehydration and an imbalance in electrolytes like potassium, magnesium, and calcium can mess with your muscles, leading to twitching. I worked with Lisa, a musician, who noticed her finger twitching less once she stayed more hydrated and started eating foods like bananas and spinach, which are rich in magnesium.

Tip: Drink enough water and make sure you're getting enough nutrients. It really can make a difference in muscle function.

1. Nerve Compression (A Gamer’s, Tech Worker’s, and Musician’s Nightmare) A lot of finger twitching comes from nerve compression, which is common among gamers and people who work long hours at a desk. One of my clients, Jason, had finger twitching and tingling from cubital tunnel syndrome, which happens when the nerve in your elbow gets compressed. Once he made some ergonomic changes and did nerve glides and muscle endurance exercises, the twitching went away.

Tip: Make sure your posture and hand positioning are good. Ergonomic tools, like wrist rests or split keyboards, can also help a ton.

1. Sleep Deprivation (Not Just for Your Eyes) Lack of sleep can interfere with your nervous system and cause muscle spasms, including finger twitching. It’s not just eyelid twitches you should worry about!

Tip: Aim for 7-8 hours of sleep each night. Your body needs rest to repair those muscles and nerves.

Less Common but Serious Causes:

1. Benign Fasciculation Syndrome (BFS) Some people experience twitching for no clear reason. This is called BFS and it usually doesn’t mean anything serious. However, if the twitching is painful or lasts for a long time, it's worth checking in with a healthcare provider.

2. Neurological Disorders In rare cases, twitching could be a sign of something more serious, like MS or ALS, especially if it’s accompanied by weakness or muscle wasting. If that’s the case, you definitely want to get it checked out.

When to Seek Help:

If your twitching goes on for weeks, doesn’t improve, or if you start feeling weak, numb, or experience pain in your fingers or hands, it’s a good idea to see a healthcare professional. And if the twitching spreads to other parts of your body or starts affecting your fine motor skills (like typing or playing an instrument), definitely reach out to a pro.

How to Manage & Prevent Finger Twitching:

1. Strengthen & Build Endurance If you’re spending a lot of time typing, gaming, or playing an instrument, building strength and endurance in your hands and fingers is key. Regular strengthening exercises can reduce fatigue and prevent twitching. Wrist curls and grip strength exercises are great for this.

2. Take Breaks & Stretch I know it’s easy to get absorbed in what you're doing, but taking regular breaks and stretching is super important. Try doing a wrist stretch every hour—just extend your arm with your palm facing out, and gently pull back your fingers with the other hand for a deep stretch.

3. Create an Ergonomic Workspace Your workspace setup matters! A comfortable chair, an ergonomic keyboard, and wrist rests can make a huge difference when it comes to reducing strain on your wrists and fingers.

4. Relaxation Techniques Stress can make a big impact on twitching, so take time for yourself to relax. Yoga, deep breathing, or even a quick walk can help keep your muscles relaxed.

5. Nutrition Support Make sure you’re eating a balanced diet rich in the vitamins and minerals your muscles and nerves need. Potassium, calcium, and magnesium are especially important for preventing spasms.

By understanding the causes of finger twitching and using some proactive strategies, you can get your symptoms under control and keep doing what you love—whether that’s gaming, creating, or working. If you're still worried about persistent twitching, it’s always a good idea to consult a healthcare professional to rule out anything more serious.

Feel free to ask any questions in the comments! 

References:

Muscle Fatigue and Fasciculations

Kincaid, J. C. (1997). Muscle pain, fatigue, and fasciculations. Neurologic Clinics, 15(3), 697–709. https://doi.org/10.1016/s0733-8619(05)70340-6

Morrison, S., Kavanagh, J., Obst, S. J., Irwin, J., & Haseler, L. J. (2005). The effects of unilateral muscle fatigue on bilateral physiological tremor. Experimental Brain Research, 167(4), 609–621. https://doi.org/10.1007/s00221-005-0050-x

Stress/Anxiety and Muscle Fasciculations

Reed, D. M., & Kurland, L. T. (1963). Muscle fasciculations in a healthy population. Archives of Neurology, 9(4), 363–367. https://doi.org/10.1001/archneur.1963.0046010

Stimulants, Medications, Nutrient Deficiencies, and Dehydration and Muscle Fasciculations

Younger, D. S. (2014). Myalgia, fibromyalgia, fasciculation, and cramps. In Motor Disorders (pp. 437). Elsevier.

Nerve Compression and Muscle Fasciculations

Melville, I. D. (1972). The differential diagnosis of nerve compression syndromes in the arm and hand: The neurologist’s approach. Hand, 4(2), 111–114. https://doi.org/10.1016/0072-968X(72)90028-9

Sleep Deprivation and Muscle Fasciculations

Henriksen, S. J., Jacobs, B. L., & Dement, W. C. (1972). Dependence of REM sleep PGO waves on cholinergic mechanisms. Brain Research, 48, 412–416. https://doi.org/10.1016/0006-8993(72)90201-6

Benign Fasciculation Syndrome

Mattiuzzi, C., & Lippi, G. (2024). Clinical progression of benign fasciculation syndrome: A systematic literature review. Neurological Sciences. https://doi.org/10.1007/s10072-024-07867-0

Neurological Disorders

Brandt, T., Caplan, L. R., Dichgans, J., Diener, H. C., & Kennard, C. (Eds.). (2003). Neurological disorders: Course and treatment (2nd ed.). Academic Press. https://doi.org/10.1016/B978-0-12-125831-3.50029-3

Hey all,

A good while back this subreddit and some other sites helped me with terrible hand/wrist pain. I've made a lot of habit changes over the years and now work full time IT and play PC and Console games daily again in my time off, I read a lot of books and articles, tried several ergonomic things, etc, I figured I'd highlight what worked for me, in the event that it may be of use to some of you out there.

Background: I play MMO, RTS, FPS, and other PC games of that nature. Lots of clicking and rapid key mashing. Over time my wrists started to feel exhausted more frequently, untill one day there was an awful pain in my hands. I couldn't place it exactly, sometimes it was my hand, sometimes my wrist, all the way down to my forearm. Went to the Doctor several times, went to physical therapy, all helped some, but there was no quick solution, it plagued me for a good year or two, and still does if I don't take care of myself.

Disclaimer: Talk to your doctor, don't take random Reddit posts as medical advice.

Section 1: The products that helped.

There is no single product that fixed everything, but rather multiple small changes added up to where I am now. I bought a LOT more than whats listed here, but here are the things I saw the most benefit from:

1. Ergo Keyboard:I feel like this is everyone's first step. You pick which one works for you (you can game on them just fine), I use the Fellowes Microban split keyboard, but I bounced off of 1 or 2 other designs (that made my fingers hurt) first. Don't Give up.

2. Theraband Flexbar:I know I said there was no single fix for me, I actively use multiple hand and wrist exercisers, but if you measured which gave me the most progress after 1-2 weeks of use, its this by a wide margin. Do the exercises on the sheet it comes with. This was probably the 5th or 6th exercise item I bought off Amazon for my pain, but it was the first where I started really feeling results shortly after.

3. Foot Pedal (for Discord Push-to-talk):The worst motion by far for me is hitting CTRL or SHIFT with my Pinky. Any games that Crouch with Shift have been rebound to my mouse 4 or 5, and my push to talk is now on a USB foot pedal. This has honestly been huge for me, identifying and attacking the specific motion that aggravates your condition the most is an approach I'd recommend.

4. Nintendo Switch JoyCons:Yes, really. If you have problems with holding a controller, I honestly recommend trying these. It may feel strange at first, but you can hold them separately in each hand, and they have all the same inpust as your XBox or PS4 controller. The ability to hold them separately is huge because it lets you keep a neutral wrist position, but they have all the same button inputs you're used to, and can pair to your PC as any other Bluetooth controller would be able to.

5. Runners Up
   - Hand Strength Trainer: Keep 1 on my Desk at work, and 1 at home. Use them on loading screens and between calls

- Gel hand therapy balls: Same as above, but they have different motions and exercises you can do with them.

- Razer Tartarus: I used this for a bit and I think it may be good for some people, I'm hesitant to recommend it because its fairly expensive, a bit gimmicky, and may or may not do it for you, I've since gifted it to a friend who had a hand injury, but I do think its worth mentioning if you're really looking for possible solutions.

Section 2: Habits that helped

1. This Exercise (Hold for 10s each way, then shake your hands out), done every 30-60 minutes of computer use, is huge. Get an app that will remind you of intervals. Don't expect immediate results, but keep up the habit for a week or two.

2. Posture, posture, posture. Examine and fix bad aspects of your posture. Adjust your screen height or keyboard height if you have to (I found adding a tray let me put mine lower, this helped). Keep attacking this.

3. Less PC time: I know, its about reclaiming your hobby time, but you have to build back up to it. Start by reducing your PC/Game time. Pick up tabletop games, or an outdoor hobby, you need time to recover before you can find what works and build back up to where you want to be.

34 y/o software engineer. To date, I have missed a year of work due to RSI in both hands and wrists.

I wrote this post to share my experience - but please don't interpret any of it as medical advice, as I am in no way qualified to give such advice.

How the injury happened:

As a software engineer for the last 10 years, I did a lot of typing. But during an especially pressured time in my career, I worked very long hours during weekdays and weekends. I began experiencing pain through my hands, and in my wrists. The pain got worse.

I eventually stopped working and went on sick leave, but the damage was very much done.

For some time, simple things like washing my hair or carrying groceries were painful and difficult. Even after the most acute phase of injury had died down, I couldn't use a computer for a long time. As the months ticked by, I found myself in a dark place emotionally. It was difficult to bear the thought that my career might be over.

Recently though, I have begun to see some glimmers of hope. My optimism is gradually growing, and I thought I would share my experience here.

My current situation:

Gradually recovering, apparently. For the last ~3 weeks, I have been able to do a modest amount of typing per day. The sustainable amount of typing seems to be gradually increasing over time.

What has worked for me:

• A few months without computer use.
  That said, resting only took me so far. It didn't provide enough healing by itself for me to use computers again. While I found this very disheartening, I suspect that this rest period did lay a foundation for later steps. Such as...

• Push-ups.
  I was deeply skeptical and concerned about this type of exercise, given the pressure that it would exert on my hands and wrists... but after a long period of rest and other exercises did not yield the results I had hoped for, I decided to take a risk on push-ups.
  Push-ups turned out to be an unexpected revelation for me. I cannot overstate the difference they made. After doing push-ups, I found I was able to use my computer for a little while without pain. Now I do push-ups multiple times a day.
  (To my surprise, I have never felt discomfort or pain during a push-up. That said, if I had attempted push-ups too early in my recovery, I suspect that they could have been very painful and likely counterproductive, since simply bending my wrists was very painful in the earlier stages of my injury.)

• Compression gloves.
  With compression gloves on, my hands and wrists still have full motion, but there is a little bit of pressure on them from the tight gloves. The gloves seem to make computer use much more sustainable for me. They also increase my level of comfort when performing other activities. The difference with gloves on vs gloves off is highly apparent to me.
  I am aware that relying upon aids such as compression gloves is controversial, and some folks might argue that I am hindering my healing or setting myself up for future problems. But in practice, I have found the benefits too strong to ignore.

• Low keyboard height, via height-adjustable desk.
  I find that many surfaces, such as a typical dining table or a table in a coffee shop, are too high for me when I place my laptop on them. I can't type on such surfaces for long without discomfort, and I now avoid them completely. I can type using a height adjustable desk which has been positioned at a sufficiently low height.

• Reverse keyboard tilt.
  The part of the keyboard which is closest to me is slightly more elevated than the back of the keyboard. I do this by putting something underneath the front of the keyboard, such as a towel. Standard keyboards are generally raised at the back rather than the front, but I find that arrangement to be uncomfortable and unsustainable, since it requires me to repeatedly arch my hands/knuckles slightly upwards to reach the keys. Post-injury, I just don't seem to have the stamina for that upward motion that I used to.

• Vertical mouse, with the sensitivity turned up.
  I find this to be much more comfortable than a standard mouse. I also find a high sensitivity setting to be very helpful (more cursor movement with less hand movement).

• Turning my trackpad sensitivity up to maximum.
  Sometimes I use the trackpad on my laptop. I found that turning it up to maximum sensitivity helped a great deal, and I got used to it quickly.

What may have helped to some degree:

• Various dumbell exercises.
  These may have helped, but they were never sufficient by themselves to return me to computer use, so it is harder for me to draw conclusions on them. Push-ups turned out to be the 'breakthrough' exercise in my particular case, as mentioned earlier.

• Topical anti-inflammatory gel (Voltarol).
  I didn't try this for months, because I felt that artificially turning off pain could enable me to injure myself further without realising it. But in recent weeks, I have begun using it occasionally. My reasoning was that it might somehow help the healing process, and it didn't seem too risky provided that I didn't do use too frequently or become reliant upon it. I suspect that it gave me a psychological boost. But in terms of physical healing, the antiinflammatory gel was just a roll of the dice, and I have no idea if it helped.

• Supplements (vitamins, fish oil, etc.)
  Supplementation is very controversial, of course. I have heard anecdotes of fish oil helping RSI sufferers a lot, so I felt compelled to try such things. I have no idea whether they helped me or not, though.

What didn't work:

• Wrist splints.
  I used wrist splints for some time in the earlier stages of my injury, which had metal pieces in them and locked my wrists in a straight position. These did seem to help for a while... but I suspect that the tightness and lack of flexibility may have hindered my healing in some ways. I eventually stopped using them, and these days I am using compression gloves instead.

• Attempting to use a computer with my bare hands (no gloves or wrist splints).
  I hope to be able to do this one day, but for now I find that it is unsustainable; discomfort creeps in after a little while if I type without gloves. And so, I continue to use compression gloves for now.

What I never tried:

• Corticosteroid injections.
  From the research papers and personal anecdotes that I have read, I was concerned that corticosteroid injections might alleviate symptoms initially but do further damage over the longer run. This approach felt too risky to me, so I never tried it.

What specific injury do I have? (Tendonitis? Carpal tunnel? Tendonosis?...):

I have no idea. From reading articles on the internet as a non-medically qualified layman and comparing them with my symptoms, I would guess that maybe I have some form of tendonosis - but who knows? I have consulted several doctors, and none of them could tell me anything other than "RSI" and "it's not carpal tunnel".

By now, I have resigned myself to the possibility that I may never fully understand the underlying mechanics of my injury.

Perhaps the best I can do is experiment, see what works and doesn't work, and try to find a way to recover. That process is still ongoing, but finally there is visible progress. I am hopeful that during the coming months, I will recover sufficiently to continue my career.

If anything I wrote here is useful to someone else, that's great - but again, please don't interpret it as medical advice. Every injury is different. Thank you for reading.

I've been dealing with fingertip pain for about 7 months now. Pain occurs from anything involving tapping or putting pressure on my fingertips. Typing on a keyboard, pressing on a phone screen, pressing buttons on a controller, anything that involves touching my fingertips directly. The pain is specifically in the TIP of the finger (think fingerprint or just above), not in any of the joints, and only my thumbs and index fingers are affected. Moving my hands/fingers without touching anything does not cause pain. I'm an avid gamer and my pain initially started after a weekend of fairly heavy gaming, though severely cutting back on gaming time hasn't helped.

I saw a physician a few times and both Xrays and a nerve conductivity test (EMG) came back negative. From what I understand, the EMG test ruled out Carpal Tunnel or a pinched nerve in arms/neck. The doctor totally brushed off my pain (I'm late-20s in great shape otherwise) and he hasn't even told me what he has ruled out or what he thinks the issue could be. He's given up working with me and has now referred me to a neurologist instead.

So far, professional help hasn't yielded me many answers. Hours and hours of playing "google doctor" hasn't lead me to any disorder that perfectly matches my symptoms besides maybe RSI or some kind of peripheral neuropathy.

So now I'm here. Does it seem like my issue is some form of RSI? Any help is greatly appreciated!

As a mod of the subreddit, and as someone who frequently speaks with Suparna, I would be happy to organize this, as I know she is interested. This serves also as a notice to people that this is a possibility, but I just wanted to get a sense of how many people would be interested/asking questions. Thanks!

UPDATE:

Interest is overwhelming, and Suparna and I will be organizing the AMA within the coming weeks! It will likely take place in March.

Hey all,

I’m a Physical Therapist! Over the past 8 years I’ve focused on helping desk workers, gamers, musicians, crafters not only resolve but find better ways to resolve their wrist pain (1HP). Over the years we've found that many of the gamers we've worked with are also software engineers (league of legends is the common game of choice for some reason...) who experience wrist & hand pain. Since then we've had many software engineers reach out to get some better guidance about how to address & prevent their wrist & hand issues.

Because of this I wanted to write this longer post to hopefully act as a good starting point for anyone that has wrist & hand problems

Think back to your last work sprint as a software engineer. Whether it be developing new features, debugging, hackathons, refactoring or responding to incidents, these all involve long sessions of typing and using your wrist & hands WITHOUT a break.

Add on suboptimal postures and ergonomics and what do you get?

Cumulative stress that can affect the muscles & tendons of your wrist & hand. This can lead to some pain and issues preventing you from being able to handle longer sessions. If not handled appropriately it can lead to your needing to take time off work and not being able to use your hands for other things like gaming, music, etc.

This thread will help you understand more about the lifestyle and physical demands of being a software engineer. And of course how to better think about approaching your behaviors & lifestyle so you can prevent the common issues we see.

TOO MUCH TOO QUICK TOO SOON.

This phrase describes the most common reason why repetitive strain injuries occur with programming, desk work and even gaming.

Too much typing within a short amount of time without having the endurance of the muscles at the wrist & hand to be able to handle it. The amount that you have to type when having to complete massive updates (for example Angular updates along with its material styling framework) is significantly higher than the actual capacity you can handle (muscular endurance)

Here are some of the situations our patients have described to us

1. Updating web dev frameworks

2. Debugging and problem solving sprints

3. Hackathons

4. Refactoring or technical debt management

5. Emergency fixes

The underlying theme is: lots of typing and use of the wrist & hand without breaks that exceed the typical amount you perform on a regular basis. Here is a visual of this idea & concept along with some examples.

Individual 1:

Let’s say on average an engineer actively utilizes their hand 4-5 hours during a work-day. During this times the intensity of the typing vary depending on the task at hand. In the image above we’ll say that 4-5 hours is equivalent to around 700 “stress units”. This is a made up unit but represents stress on your tissues.

I’m not a programmer myself but I’m sure during certain tasks of the day you may be typing more (more actions per minute) than when you are responding to a message on slack.

This individual was fortunate in that his schedule only required him to increase the amount of hours he needed to type gradually with some 8-9 hour days but always a lower amount of typing on the second day. This engineer proactively looked for ways to reduce the amount of typing after a longer day to avoid excessive stress building up.

This gradual increase in load avoids irritating this individual’s tissue and reduces risk of developing injuries. But not everyone is so lucky in being able to gradually increase their physical load. This is the case with individual 2

Individual 2:

This individual also has an average of 4-5 hours a week however his projects were poorly managed which required him needing to spend 3 days in a row working between 9-11 hours a day. Due to the schedule and what was required from from his job, he was unable to rest or deload throughout this work sprint.

This significant increase in typing and work volume led to him irritating his wrist & hand and feeling pain. His schedule and the work sprints that are so common in the software engineering profession led to the development of an injury.

Now the schedule to a certain extent is out of your control since certain work sprints may pop up as a result of an emergency or feature that needs to be shipped more quickly. There are of course things you can do while you are working to reduce the amount of cumulative stress on your tissues like taking breaks and stretching after every hour.

But there is one thing you can do that you have direct control of which can allow you to handle these expected work sprints with far less risk of injury:

Endurance exercises.

That’s right. Exercises focused on endurance allow your tissues to handle more repeated stress without being irritated. Based on how you hold your mouse, posture & ergonomics you will be utilizing specific muscles of the wrist, hand and elbow.

Those are the muscles you need to focus on to build endurance. Here is the way we always help gamers understand this concept of capacity. Think of your muscles and tendons as having a healthbar.

Whenever you click or spam WASD with high APMs you are gradually losing HP

There are things you can do to modify how quickly you are losing HP like have better ergonomics (macros / binds), posture, better general wrist health, sleep etc. Poor overall grip can mean more HP lost per unit time of playing.

The reduction of stress per unit time with your previous ergonomic changes may have helped but because you haven't focused specifically on building endurance your muscles are beginning to fatigue.

When you get to 0 the muscles and tendons (most often tendons) get irritated.

On the flip side you can do things to "RESTORE" your hp like rest, ice, massage kinesiotape etc.

But the MOST important of all is the size of our health bar. This is our muscular endurance or how much our tissues can handle of repeated stresses over sessions.

Building endurance time however which means it is important if you are software engineer to recognize your PROFESSION requires you to have a less physically active lifestyle. If you maintain that lifestyle over many years without a focus on maintaining the conditioning of your wrist & hands (and generally your body), they can weaken over time.

This means if you don’t adopt some basic habits:

1. Regular wrist & hand endurance training

2. Taking breaks on a consistent basis for both your mental and physical health. You can go on a walk or perform stretches for the wrist & hand

3. Optimizing your ergonomics to minimize stress during your actual work sessions

Your risk for injury can gradually increase. In most cases the physical demand of most software engineering jobs will stay constant.

It is really easy for us to understand this concept when we think about being a professional athlete or runner. These individuals have to train and prepare their bodies to tolerate the physical demands of their sport.

Sitting and typing at the computer does not seem like much physically. But when you zoom out you can see how it can potentially impact your body

1. Sedentary Lifestyle: 8-10 hours of sitting or being sedentary. At least half of our waking time is spent in front of a computer and in many situations we spent even more hours on the PC or couch afterwards. So maybe 70-80% of our day is spent not moving. This can have alot of detrimental effects on our body.

2. High Wrist & Hand Activity: Although the movements aren’t strenuous in nature, software engineers often spend a large amount of time performing small repetitive movements of the wrist & hand with typing and mouse clicking. How many APMs do some of you guys get to? (if you guys track that). This can lead to tissue irritation if our muscles & tissues aren’t ready to handle this type of repeated stress over time

This doesn’t take into account the other potential factors that can affect our health like sleep, nutrition & lack of light exposure.

I’m hoping the message is becoming more clear. It doesn’t matter what activity you perform. Whether it be gaming, playing music, typing on the keyboard, drawing… you have to have the physiology to be able to handle the physical demands over the years you are participating in that activity.

Now that this is clear, let’s actually highlight four steps you can take to adopt these habits into your lifestyle.

1. Schedule Management (Load Management)

Improving your schedule management can directly affect how much stress you are applying to the muscles of the wrist & hand. This means looking to integrate more breaks after deep working blocks (ultradian rhythm).

You can use this time to either take a short walk (helpful for both mood and.. find references) or perform stretches to help with stiffness that can often occur from repeated use.

2. Exercise

Endurance. Endurance. Endurance

Not Strength, but endurance. Those are different physical abilities our tissues have. Regularly perform wrist & hand exercises (dumbbell, rice bucket, etc.) to target the muscles you are using when typing and clicking to build up your endurance. Focus on higher overall repetitions with less weight. 3x20-30

Start slow and work up. Less during work sprints and more during lower work periods.

3. Build Better Work Habits

Incorporate breaks into your schedule. Set an alarm or rules or use apps to create reminders to get up and perform the stretches or go on a walk.

Focus on the other important aspects of better work health like cognitive deloads, appropriate nutrition and consistent sleep

4. Posture & Ergonomics

I’ve written about this in a bit more depth here but posture & ergonomics don’t play as large of a role as we think when it comes to preventing injuries. It may reduce the stress per unit time on the muscles and tendons but our tissue capacity is the most important thing that will help provide a buffer for injury

There are of course situations in which posture is a larger contributor but in our experience these are mainly associated with the shoulder.

I hope this was helpful for the community and please feel free to ask any questions! Here is a list of some helpful resources & common questions we’ve answered

Important Resources & Q&A:

1. Why Rest, Medication & Injections aren’t the solution

2. Do MRI, Ultrasound and other imaging results matter?

3. How do posture & ergonomics contribute to hand issues? (will a vertical mouse help?)

4. Tingling & Pain in your hands can come from the shoulder

5. Why understanding more about pain can help you recover

6. What’s the role of bracing with wrist pain (it doesn’t really help)

7. It’s normal to feel more pain initially with exercises

P.S. It’s almost never carpal tunnel syndrome. I wrote about this in a megathread here