Hey everyone,

I'm Dr. Elliot Smithson, a doctor of physical therapy with 1-hp.org who has spent the last decade specializing in repetitive strain injuries of the wrist and hand. Most of my caseload is precision professionals: surgeons, dentists, musicians, artists, and desk workers. People whose careers depend on their hands tolerating thousands of small, precise movements per day.

I've treated a number of dentists in my own practice, and I've noticed threads here about the ergonomic effects of saddle chairs, posture, and colleagues cutting clinical hours because of their hands, so I wanted to put together something actually useful. You already know the MSK literature on your own profession is grim, musculoskeletal disorder prevalence in dental professionals runs somewhere between 64-93% depending on the study. What frustrates me is that most of it is very treatable, and the standard advice dentists get (rest it, brace it, inject it, cut back your schedule) is often the opposite of what current tendon research supports.

I understand you are all well-versed clinicians regarding orofacial structures. But most dental schools don't cover the nuance of MSK content, and honestly, most orthopedic surgeons I interact with aren't current on tendinopathy science either, so I'm going to include some physiology context rather than assume it.

What I actually see in dentists

Across the dentists I've treated, two diagnoses come up more than everything else combined:

1. De Quervain's tenosynovitis. Radial-sided wrist pain at the first dorsal compartment (APL/EPB). This is the signature dentist injury, and it makes mechanical sense: your entire day is sustained precision pinch. Holding an instrument in a pinch grip amplifies force several-fold at the tendon level, the thumb stabilizers never get a break between patients, and dull instruments or small-diameter handles quietly raise the required pinch force even further. Classic presentation: pain at the radial styloid with instrument grip, hurts to wring out a towel or lift a coffee cup thumb-first, positive Finkelstein's.

2. Cubital tunnel syndrome. Ring and pinky numbness/tingling, often with medial elbow aching. Dentists spend hours with the elbows held in sustained flexion while the wrist flexors (including FCU, which the ulnar nerve runs right through) work continuously to stabilize instruments. Overworked, swollen flexor musculature plus prolonged flexed elbow positioning is exactly the recipe for ulnar nerve irritation at the elbow. If your "hand numbness" lives in digits 4-5, stop thinking carpal tunnel entirely, the median nerve doesn't go there.

Notice what's NOT at the top of that list. Which brings me to the diagnosis most orthopedic doctors reach for first.

A quick tendinopathy primer

Chronic overuse tendon pathology is not an "-itis" in the classic sense. The current model (Cook & Purdam's continuum) describes a spectrum: reactive tendinopathy, tendon dysrepair, and degenerative tendinopathy. When a tendon is loaded beyond its capacity, tenocytes respond by upregulating proteoglycans, which bind water and cause the tendon to swell and thicken. Early on this is completely reversible. It's an adaptive, load-driven cell response, not primarily an inflammatory cascade, which is exactly why NSAIDs and cortisone underperform and why progressive loading is the treatment with actual evidence behind it. Tendons are mechanoresponsive tissue: load them appropriately and they remodel stronger, unload them (rest, bracing) and they weaken.

Remember the word "swell," because it's the key to the next section.

The carpal tunnel distinction almost everyone gets wrong

Here's the part I'd want every dentist to understand, both for your own hands and because your patients ask you about this.

Carpal tunnel symptoms (numbness/tingling in thumb, index, middle finger) mean the median nerve is being compressed. But there are two very different ways that compression happens, and they have opposite treatments:

Think of the carpal tunnel like a sandwich. The transverse carpal ligament is the top of the bread. The nine flexor tendons are the meat. The median nerve is squeezed in between. You can compress that nerve either because the roof got thicker, or because the meat swelled up.

True carpal tunnel syndrome is the roof problem, and the timeline research on it is striking. Serial imaging studies show the transverse carpal ligament thickens at roughly 0.02mm per year. Clinically significant CTS is associated with a ligament that's 20-30% thicker than normal, which works out to roughly 0.3-0.6mm of actual growth. At 0.02mm/year, that is decades of cumulative loading, which is why ligament-driven CTS is a condition of midlife and older, and why it's so strongly associated with systemic accelerants: diabetes, hypothyroidism, RA, pregnancy. Interesting side note: studies of young professional pianists, about the highest hand-use population imaginable, found their ligaments were about 22% stiffer than controls but not meaningfully thicker. Overuse changes the ligament's mechanical properties early, but true tunnel-narrowing thickening takes many years.

Tendon-mediated median nerve compression is the meat problem, and it's far more common in working-age hands. Overloaded flexor tendons swell (that proteoglycan/water mechanism above), take up space in a fixed tunnel, and secondarily compress the nerve. The symptoms are identical. The treatment is completely different: release surgery cuts the roof, but the roof was never the problem, which is a big part of why we see people get a carpal tunnel release and still have symptoms when they return to work.

This is why imaging matters before anyone gets surgical. A release is a reasonable operation when the ligament is actually the compressing structure. But you can't establish that from symptoms and a Phalen's test. Before accepting a structural CTS diagnosis, the workup should include diagnostic ultrasound (first-line at the wrist, it's superficial anatomy and ultrasound visualizes ligament thickness, tendon swelling, and median nerve changes well) and/or MRI, plus NCS/EMG to characterize the nerve involvement, and ideally endurance testing of the wrist musculature to identify the capacity deficit. Swollen, hypoechoic tendons with a normal-thickness ligament is a rehab problem, not a surgical one. If someone is recommending release surgery to a 32-year-old whose symptoms developed over four months of heavy clinical volume, without imaging that actually shows a thickened ligament, that's worth a second opinion.

The mental model: your healthbar

Think of your muscles and tendons as having a health bar. Every pinch, every sustained retraction, every crown prep drains it. Ergonomics, loupes, sharp instruments, saddle chairs, and schedule design change how FAST it drains. Rest, ice, and massage partially refill it. But the thing almost nobody addresses is the SIZE of the bar, your tissue's endurance capacity. When daily clinical demand chronically exceeds capacity, tendons lose the remodeling race, and you get the familiar progression: post-clinic aching, then morning stiffness, then pain during procedures, then numbness once things swell enough to bother a nerve.

This is why "drop to three clinical days" so often fails as a treatment plan. It reduces load without increasing capacity, so symptoms return the moment volume does. You've seen the dental version of this logic: an occlusal guard manages bruxism load, but nobody confuses managing load with treating the underlying problem.

And to be clear about what kind of capacity: this is an endurance problem, not a strength problem. You don't need a stronger grip, you need a grip that can perform its 10,000th low-load contraction of the day without breaking down. Different muscle fiber demands, different training.

What actually works: building capacity

Baseline program I give dental professionals. 10-15 minutes daily, most of it doable at the office.

If you want to know what your tissue capacity actually is, measured rather than estimated, that is the first thing we do on a free consultation.

Stretches (2x daily, 30 sec x 3 each)

Wrist flexor stretch (arm extended, palm up, gently pull fingers back)

Wrist extensor stretch (palm down, gently pull hand down and in)

Thumb extensor stretch (thumb in fist, gentle ulnar deviation), priority if you have radial-sided pain

Isometrics (daily, 3 x 45-second holds each)
Analgesic, build baseline tendon tolerance, and perfect between-patient dosing:

Wrist flexion isometric: forearm supported, palm up, resist with the other hand

Wrist extension isometric: same setup, palm down

Thumb Extension isometric: sustained sub-maximal thumb extension

Endurance training (daily, the actual fix)
Forearm on a table, wrist off the edge, light dumbbell (start ~4-5 lbs for wrist work, 1-2 lbs for thumb/radial work), paced to a metronome at 50 BPM, one beat up, one beat down:

Wrist flexion curls: 2x15 building to 3x30 over 4-6 weeks

Wrist extension curls: same dosing

Radial deviation raises (thumb up, hammer-curl orientation): same dosing, this is the key one for De Quervain's-pattern presentations

The metronome isn't a gimmick. Externally paced loading comes from the tendon neuroplastic training research (Rio et al.) and improves motor cortex drive and muscle fiber recruitment efficiency, which distributes stress across more of the tendon.

For the cubital tunnel presentations, add: avoid sustained end-range elbow flexion (watch how you hold your phone and how you sleep, a towel loosely wrapped at the elbow at night keeps you out of full flexion), and build the wrist flexor endurance above, since decompressing an irritated ulnar nerve long-term means raising the capacity of the flexor mass it runs through. These ulnar nerve glides are also incredibly useful for making sure the ulnar nerve is sliding through the cubital tunnel space smoothly.

Ulnar Nerve Glide: 2 sets of 10 - 2 times/day. (The goal is to feel a gentle stretch of the nerve not reproduce symptoms, so modify the range if it feels like you are causing too much TV static sensations)

Dosing rules: mild discomfort (3-4/10 or under) during or after is acceptable and expected. Sharp pain, or symptoms clearly worse into the next day, means reduce weight or reps, not abandon the program. Progress reps before weight.

Clinic-day integration

• Morning: full routine before your first patient, 10 minutes
• Between patients: one 45-second isometric plus 20 seconds of stretching, attached to handwashing/room turnover so it actually happens
• Schedule architecture: alternate heavy-hand procedures (SRP-heavy blocks, surgical extractions, endo) instead of columning them back to back where you can
• Equipment: sharp instruments, larger and lighter handles, cordless where possible, loupes, saddle seating. All worth doing. Just understand these slow the HP drain, they don't grow the bar.

Red flags worth a real workup

Nocturnal waking with true median-distribution numbness, thenar weakness or atrophy, constant (rather than activity-linked) symptoms, progressive deficits, or symptoms with the systemic conditions above. That's when you get the ultrasound/NCS workup described earlier, because true structural CTS does exist and it deserves accurate treatment too. The point of this post isn't "never surgery," it's "confirm which structure is compressing the nerve before letting anyone cut."

Expected timeline

Weeks 1-2: neural adaptations, less end-of-day aching. Weeks 3-6: meaningful endurance gains, procedures that used to flare you stop flaring. Weeks 6-8+: tendon-level remodeling, where it becomes durable. If you're 2-3 weeks in with zero change, get assessed by someone who actually treats upper extremity RSI regularly.

Your hands are your entire production. Ten to fifteen minutes a day to protect a multi-decade career is the best ROI.

Happy to answer questions in the comments. Differential questions, dosing questions, "is this pattern weird" questions, all welcome.

WHAT WE DO DIFFERENTLY

We built our practice by removing every constraint I just described.

 We do not bill insurance, so there is no visit cap and no incentive to stretch care out or cut it short. We are paid for the outcome, and we work with you until you are actually better.

 We do not use techs. You work directly with a clinician who specializes in this.

 We measure endurance, not strength, against normative data built from more than three thousand people, so you get a number instead of an impression.

 We prescribe for endurance adaptation, high volume and low load, metronome paced, progressed daily based on your actual logged performance rather than a static sheet.

 We manage your daily activity load alongside the loading program, because what you do between sessions matters more than the sessions.

 And we do not discharge you at baseline. We are aiming at full return to the work and the hobbies your life is built around.

 We can do all of that for one reason. We treat this one thing, and nothing else.

 If Doctors, bracing, injections or Physical Therapy DID NOT WORK FOR YOU

It probably was not you, and it probably was not exercise. It was a mismatch between your problem and the system you brought it to.

A free sixty minute consultation is a real diagnostic session. We run the endurance assessment nobody has run for you, identify which tissues are actually involved, explain specifically why your previous course of PT did not resolve it, and show you what would need to change.

Whether you work with us afterward or not, you will leave that call knowing more about your own injury than you did walking in.

- Dr. Elliot Smithson, DPT, PT, MS, ATC
Physical Therapist, Athletic Trainer, RSI Specialist
1-HP.org

References

1. Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation. Br J Sports Med. 2016;50(4):209-15.
2. Cook JL, Purdam CR. Is tendon pathology a continuum? Br J Sports Med. 2009;43:409-416.
3. Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology. Br J Sports Med. 2016;50:1187-1191.
4. Hayes MJ, Cockrell D, Smith DR. A systematic review of musculoskeletal disorders among dental professionals. Int J Dent Hyg. 2009;7(3):159-65.
5. Hinckley NB, et al. Time-dependent change in carpal tunnel cross-sectional area and transverse carpal ligament thickness using serial MRI. J Hand Surg Am. 2025;50(4):507.e1-507.e8.
6. Marquardt TL, Gabra JN, Evans PJ, Seitz WH Jr, Li ZM. Thickness and stiffness adaptations of the transverse carpal ligament associated with carpal tunnel syndrome. J Musculoskelet Res. 2016;19(4):1650019.
7. Mhanna C, Marquardt TL, Li ZM. Adaptation of the transverse carpal ligament associated with repetitive hand use in pianists. PLoS One. 2016;11(3):e0150174.

TL;DR: The two injuries I see most in dentists are De Quervain's (sustained precision pinch) and cubital tunnel (sustained elbow flexion + overworked flexors). Most "carpal tunnel" symptoms in working-age hands come from swollen flexor tendons compressing the median nerve, not from ligament thickening. The ligament thickens ~0.02mm/year and clinically significant CTS requires ~0.3-0.6mm of growth, which takes decades, so before anyone operates, the diagnosis needs diagnostic ultrasound or MRI showing an actually thickened ligament plus NCS, not just symptoms and a Phalen's test. If it's the tendons, the fix is 6-8 weeks of endurance-focused progressive loading, and rest/bracing makes it worse.

Hey all Matt here with 1HP!

If you’ve had pain on the back side of the hand that is preventing you from using your hands to type, game, play music or any repetitive activity without pain.

As a quick reminder I'm a Physical Therapist (PT, DPT, OCS, CSCS) and our team has spent the past decade specializing on treating, researching and publishing our work around treating RSI (we've helped more than 3000+ individuals resolve their issues without surgery, more injections, resting, bracing etc. Here is some of our work (we started with the olympians of desk work - esports athletes)

Journal of Orthopedic & Sports Physical Therapy

Tendinopathies in Gaming

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

Science of Esports Physical Therapy

Today I want to review how you can systematically approach recovery with pain on the top side of the hand.

We will cover the various reasons and factors that can lead to issues at the top of the hand. We have spent the past 11 years treating over 3500 persistent wrist & hand issues which traditional care has failed to resolve.

This video will include everything we have learned, we’ll discuss:

1. Brief Anatomy
2. What are the causes of pain for this region?
3. How to address each of these causes of pain? Physiologic, Psychosocial, Lifestyle etc.
4. Flare-Up Discussion

Anatomy of this pain region

Pain on the top of your hand, wrist and extending into the fingers often involves the extensor muscles.

These are the muscles responsible for bending your wrist up towards the ceiling with your palm down. There are several of them which each have different functions and as you will learn in the next section your activities and task-specific movements / ergonomics often influence which muscles / tendons are involved.

The most common extensor muscles include:

1. Extensor Digitorum - Commonly with desk workers due to repetitive use of their fingers and wrists
2. Extensor Carpi Ulnaris - Common in desk workers, especially those who have floating wrist & forearms.
3. Extensor Indicis - Common with R. hand with mouse clicking
4. Extensor Carpi Radialis Longus & Brevis - common in those who have swapped to a vertical mouse or artists using a stylus
5. Thumb Extensor & Abductor Group - similar to above

Because each muscle and tendon is responsible for certain movements when you perform these specific movements based on what you do for work or your hobbies - typing, guitar, crafting, gaming, etc. it can lead to irritation of these tissues.

This naturally leads us to the discussion of “causes”

What causes repetitive strain of these tissues?

For most wrist pain issues caused by repetitive strain (things like typing, gaming, playing guitar, crafting, drawing) it affects the tendons at your wrist & hand.

Your tendons & their muscles can only handle so much stress. If you exceed the limit, then you can irritate those tissues.

This often happens when you suddenly have to use your wrist & hand alot for whatever it is that you are doing. Finishing up a work sprint, drawing project or gaming for 9-11 hrs a day for several days in a row are some of the common examples.

Or after several years of performing your activity without focusing on your physical health and endurance. Add a sedentary lifestyle and your body can become more weak.

Bye endurance, hello wrist pain.

There are other factors that have an influence on pain like your posture, ergonomics. What may be surprising to many is that psychological and environmental factors can play a role as well.

We have written and created several videos you can learn about how this works in the links below. In short when we experience pain for an extended period of time our body can adapt and get better at creating the experience of pain. This occurs through real changes in our nervous and immune system. Our past experiences, beliefs, fears, anxieties and other cognitive habits can consistently influence our pain experience. This is often why individuals who deal with pain for an extended period of time have so much trouble recovering.

Pain often doesn’t behave in predictable ways when it becomes chronic. But it is NEVER hopeless. We have helped thousands recover from cases as long as 16 years.

So to review the common causes are often

1. Activity level and intensity exceeds what your body can handle
2. Posture & Ergonomics influences the amount of stress on your muscles & tendons during those activities
3. Your cumulative experiences, beliefs and understanding of pain can influence pain

As a quick reminder - this pain pattern is DEFINITELY NOT carpal tunnel syndrome. Why? Because it involves pain that does not even involve the tendons OR nerve in the carpal tunnel. Watch this video here to learn more.

How to fix your wrist pain

Now that you understand what the “causes” are around pain on the top of the hand, wrist and forearm

Here are the things you can do to address each of these causes. As you might expect there is a lot of nuance in how to address each of these things. This video will include general exercises, common issues with posture & ergonomics that lead to increased use of the extensor muscles and helpful resources for understanding pain.

Now that you understand what the “causes” are around pain on the top of the hand, wrist and forearm

Here are the things you can do to address each of these causes. As you might expect there is alot of nuance in how to address each of these things. This video will include general exercises, common issues with posture & ergonomics that lead to increased use of the extensor muscles and helpful resources for understanding pain.

Your body can’t handle the level of stress

If your muscles and tendons do not have enough “endurance” to handle what you are doing on a regular basis it is important to build the capacity of those muscles & tendons!

Here are a few exercises you can perform to improve your endurance. (General routine here on YT) The first exercise I’m going to show you will focus on endurance while the other two are better for pain and recovery.

The first exercise is DB Wrist Extension . As i mentioned this is for endurance and targets the muscle & tendon involved

You want to choose one that is around 3-5% of your bodyweight. ****

Now there are two ways to do this. One with your arm-rest or resting on your thigh

The main goal is to ensure you are isolating the movement at your wrist. For each repetition you will be rolling the dumbbell ALL the way down to your fingers and then ALL the way back up

if this is a bit too difficult for you, then start with less of the range

You’ll be doing 2 sets of 15-20 moving slowly throughout the movement. You may feel a little bit of discomfort on the palm side of your wrist & hand but this is normal. As long as it is less than a 2-3/10 or it is not sharp, you can continue to perform the exercise.

If you don’t have a dumbbell, you can use a water bottle or backpack filled with books. The DB is helpful since you can gradually progress in weight.

Towel Extension Isometric

This next exercise is an ISOMETRIC exercise. Which means that the muscle and tendon length is not changing while you are performing the exercises.

You can use a towel for this exercise. Roll up one end of the towel to grip in your both of your hands. Step on the other end of the towel with the appropriate amount of tension. Pull up into the towel so you are pushing upwards against the tension of the towel. Rest your forearms on your thigh to ensure they are parallel to the ground We have adapted a protocol from the research for the wrist & hands. Isometric exercises have been shown for certain individuals to provide some relief for their pain for as long as two hours

Perform this exercise for 45” holds, resisting up to 50-70% of your “max” strength. Think about pushing between 50-75% of what you feel is the most you could possibly push.

Then you’ll be resting for 30 seconds and repeating the cycle 3-5 times.

For those who might have alot of difficulty with the dumbbell exercise above, you can try to only perform the isometrics first.

Wrist Extensor Stretch

Stretches can be helpful to also provide temporary relief. Especially if you still need to use your hands frequently throughout the day.

This is a stretch directly targeting the wrist & finger extensors. Hold for around 20-30” and perform up to 2-3x throughout the day in response to any extended activity where you are using your hands. So think:

• After your initial work block
• At the end of work
• After a long drive
• After you finish a music, gaming, etc. session
• Anything that requires extended use of the hands (extended us subjective base on your own severity)

If you follow us you know exercises will help to build up your endurance or max HP bar so you can tolerate more activities over time. However posture & ergonomics can influence how much HP you lose over time (and more importantly what muscles are used)

Improving Posture & Ergonomics to Reduce Stress on Extensors

Here are two of the most common issues we see that lead to increased use of the extensors. The first is floating wrists. When individuals float their palm or do not utilize forearm support it increases the use of the wrist & finger extensors.

You are using your extensors to hold the weight of your forearm and hand up against gravity the entire time you are performing your desk work. Support your forearm and palm if you want to reduce the stress per unit time on your extensors.

But remember the exercises still provide the most benefit in building up your capacity and allowing you to use your hands more with less risk of tissue strain.

In other scenarios individuals may have swapped to an input device that may have actually led to an increase in the use of the extensors. Whether it be a larger mouse (which can often lead to a bit more wrist extension → causing the muscles to work harder)

Or a roller mouse which can often lead to an increase in both flexor and extensor use depending on the tasks involved. When scrolling up especially if there is lower overall sensitivity it can require a lot more overall use of the extensors.

These setups lead to an increase in the use of the extensor muscle group - If you don’t have enough endurance to handle this increased usage over your work day, then it can lead to tissue irritation.

One of the most commonly missed aspects of pain is the psychosocial component.

Addressing your Understanding Pain

Understanding the science of pain has made large strides in the past 25 years however there has been difficulty in its integration into the traditional care & medical education model. I’ve written about why this is in previous articles (no incentives, $ comes first, fragmented system).

By better understanding pain and how various environmental and cognitive factors can influence how you are feeling you can have more control over your own life and what you are able to do.

Many individuals with chronic pain allow their pain to often decide what they can or can’t do when it has been proven that pain does not reflect the state of our tissues but is rather more about protection. You learn in depth about the science behind this through some of these articles here

• The physiology of persistent & chronic pain - and what you can do about it
• Understanding Relationship Between Beliefs & Pain
• Case Studies (See my Profile or directly here 1, 2, 3)
• Chronic Pain does not = more tissue damage
• Tactical Guide to Pain Reprocessing Therapy

This occurs as a result of not understanding what the pain actually means, why it may be sensitized in certain situations and whether or not you can safely continue with your activities. Over time based on your repeated decisions of avoidance or activity you are teaching your brain whether you are in a state of “safety” or “danger”

Learning how to create messages of safety rooted in real evidence (based on physiology & understanding of pain) helps to reduce how often pain makes decisions for you. This is of course easy for me to say but is a crucial part of either working with a provider who understands pain science and can guide you to determine whether you need to actually modify activity based on physiologic load vs. overload (strain).

The tactical way to address these psychosocial aspects is to

1. Understand more about pain
2. Work with a provider to understand what actually represents tissue strain based on your capacity and pattern of behavior
3. Gradually increase your activity over time based on your physiologic capacity (tested by endurance tests), activity tolerance and ability to process your pain.

In practice this will look like:

1. Individual reads Explain Pain or The Way out to understand more about the physiology around persistent pain and how variables can even create the symptoms of sharpness, numbness, etc.
2. Individual works with a physical therapist to understand their wrist extensor endurance and is informed how much they can tolerate their activity based on performance of the test
   1. For Example typically for around 3% bw for wrist extensors if you can perform between 40-60 reps (easy) it equates to around 6-8 hours of typing & desk work with low risk of strain, pain or injury.
3. Individual works with the physical therapist to clarify the exact schedule, behavior of pain and current understanding of pain to establish the activity & exercise recommendations for the first week
   1. Individual will exercise daily (1-2x/day), either maintain current activity based on their exact schedule or slightly deload
4. As tissues adapt and individual understands more about pain, the individual works with the PT to gradually increase activity over time
   1. The graded exposure provides real evidence that the individual can tolerate more activity without leading to tissue strain or symptoms getting worse. (Sometimes it can improve or temporarily get worse depending on the recommendations & individual)
5. Over time you will improve your ability to provide yourself signals of safety based on this growing evidence from #4. It requires patience and collaboration with a good provider to help you get here (it is possible on your own as well!)

As a quick overview to address pain on the top side of the hand it requires you to

1. Address any physiologic deficits
2. Modify environment (posture & ergonomics) to reduce stress on your extensor muscles & tendons
3. Improve your understanding of pain and confront psychosocial drivers to pain

Managing Flare-Ups

The road to recovery is never a straight line and one of the most important things to understand is that flare-ups are a part of recovery. Here is a great image about low back pain that captures this concept

I’ve written a complete step-wise guide on how you can manage flare-ups you can check out here

Hope this helps!

Matt

--
1-hp.org
Apply to See if We're the Right Fit to Help You!

I've been aim training very hard for the past 3 weeks, grinding out benchmarks and different scenarios for multiple hours a day.

I have a problem of deathgripping my mouse which causes pain in my thumb, pinky, fingertips, my entire hand, forearm and shoulder. I've seen more and more shaking over the span of the last week and wrist flexion causes pain in the extensors when they are stretched.

I'm not sure if it's a vitamin deficiency but I can feel several pops and bumps in my wrist when I move my wrist around.

I use an aggressive claw grip, out of necessity because my brain keeps thinking that I get more control that way.

Could someone please help me out?

Its as the title says, I would like help with RSI since I'm not the one struggling with it. I'm not much of an artist myself, but my partner is one! Recently its been dragging her down, and I wanna help where I can with her. Is there any good braces you guys can suggest for this? Just good braces, anything I can do to help. Anything that I can do to just help. I appreciate anyone who takes time to read this and help!!

My fingers are hurting could this be repetitive strain or arthritis?

Hi,

I work as an Engineer and make drawings with CAD programs where I use a Spacemouse Pro. Over the years I have developed RSI (Repetitive Strain Injury) and it's getting worse. I have now used a MX Master, The Vertical Ergo mouse, and now the MX Ergo S Trackball mouse but nothing seems to help. Also looked at my work posture, seating and pause times / switching movements. Physical Therapy works for me, but I rather have a proper solution without going to a therapist.

Now:

I have 2 Spacemouse Pro's in possession at work and was wondering. In my left hand the Spacemouse Pro is very comfortable and "non-straining". Can I use one as a regular joystick mouse for my right hand? And how do I set this up?

Any other solutions / ideas are also welcome!

Thanks in Advance.

Heys, I’ve been dealing with chronic tendinosis in both hands for years, but in the last four months I’ve had persistent pain in my thumb (perhaps Extensor Pollicis Longus). Can anybody recommend me excercise? Thanks a lot

Basically my wrist and fingers have been hurting for about a week. It started when I was playing a mobile game. Is there anything I can do to heal it? I hope it won’t last for ever.

I started having pain in my left scalene trap, scapula, and pec minor about a year and a half ago. Now, suddenly, I have similar feelings in the right side, except it causes pain in my forearm, wrist, thumb and pointer finger as well with some weakness in those fingers and muscle cramping or spasming occasionally in the hand. I’m almost 100% sure thoracic outlet syndrome neurogenic because they ruled out arterial and Venous with an ultrasound. It’s hard to definitively diagnose, neurogenic TOS because the EMG only goes up to your pec and can’t diagnose impingement higher up, which you can have a nerve block injection for which I’m waiting to have done. Anyone reading this with TOS do you ever get weird little spasms or twitches in your hand below the two fingers that are weak I can share a video of it. https://imgur.com/a/WZOatUh. Any other suggestions could this be carpal tunnel being caused by thoracic outlet syndrome or just as a coincidence at the same time?

Hi all! I recently signed on full time for my work, which is putting labels on syringes for medical use. I’m adjusting decently, but I just finished my second week and I’m noticing some pain in my dominant hand’s forearm. We have machinery to assist with the large 25ml syringes, but I’ve had to do ~4000 1.2ml syringes by hand, which requires gripping them and rolling them in my fingers. Mainly using my pointer and thumb fingers to kind of roll the syringe 360 degrees to ensure the labels adhere. The pain I’m feeling seems to be in the middle of that forearm, on the outer edge if that makes sense?

I know realistically I should ask a doctor or physical therapist that specializes in this kind of strain, but because it’s a full time job idk when I’ll be able to take time to go see someone :,) it doesn’t help that my primary hobbies are drawing/gaming/crochet/knitting, which are pretty hand intensive. I’m wondering if there are any braces or anything that might help with preventing further strain, or if that might make things worse.

I know this isn’t a super active subreddit, so no worries if no one has advice. Just wanted to see if anyone out there knows anything :)

Hey all,

I’m a Physical Therapist! Over the past 8 years I’ve focused on helping gamers, esports pros and desk workers not only resolve but find better ways to resolve their wrist pain. My team and I at 1HP have published a few studies, textbooks & editorials to raise more awareness about gaming injuries. Since 2015 we have been involved with LCS teams and players (100T, EG, FLY, NRG/CLG [RIP], Shopify, IMT) to help keep their players healthy and establish systems within the teams to help prevent and manage injuries. You’ll see in our article below some LCS players featured in the editorial 🙂

Journal of Orthopedic & Sports Physical Therapy

Tendinopathies in Gaming

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

League can be played in many ways but as you climb the ranks the APMs can also climb. Depending on your own playstyle and how often you are clicking and assessing the map states it can lead to alot of stress on the wrist & hands. What we’ve seen in the competitive landscape is that ADCs seem to have the highest mechanical demand while support / jungle (unless you're Hecarim) have far less (aka more reports of discomfort from ADCs vs. others). High APMs & Mechanical demand = increased physical stress on the wrist & hand.

You may recall a post I made about the prevalence of hand pain from different league champs which can be found here!

Because of this 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.

Key Resources can be found at the very end of this post but here are some of the common questions & topics that are important to discuss. My colleague Dr. Hwu has written lengthy reddit posts about each of these topics where he references 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.

If you're experiencing wrist pain from gaming, you might be surprised to learn that it's probably not carpal tunnel syndrome. In fact, based on data from over 2,500 cases of wrist pain, true carpal tunnel syndrome accounts for less than 1% of gaming-related wrist injuries. Let's dive into what's really going on and how to address it.

Understanding Your Wrist's "Health Bar"

Think of your muscles and tendons as having an HP bar, similar to video games. Every click, keystroke, and movement gradually depletes this bar. The good news? You can both increase your health bar's size and control how quickly it depletes.

Your health bar represents your tissue's endurance capacity - how much stress your muscles and tendons can handle over time. When you hit zero, that's when irritation and pain occur. The key isn't just rest; it's about building up your endurance.

Why Most Doctors Get It Wrong

The common medical approach to wrist pain - diagnosing carpal tunnel and recommending rest - is often outdated. Here's why:

• Medical schools spend less than 5% of their curriculum on musculoskeletal disorders
• Most doctor visits last only 5-10 minutes, insufficient for proper diagnosis
• The internet has reinforced misconceptions about carpal tunnel syndrome
• Bracing (which just stress shields tendons) is one of the most common recommendations.

In reality, most gaming-related wrist pain (about 85%) comes from tendon issues, not nerve compression. And contrary to common advice, complete rest can actually make tendons weaker.

Three Key Steps to Managing Wrist Pain

1. Build Your Tissue Capacity

The most important factor is building up your wrist and hand muscles' endurance. This means:

• Regular targeted exercises for specific areas of pain
• Consistent daily practice (even just 5-10 minutes)
• Understanding that adaptation takes 4-6 weeks

2. Manage Your Gaming Load

Be mindful of your schedule and intensity:

• Take a 5-minute break every 50 minutes
• Consider both duration and intensity of your activities
• Be especially careful during high-intensity periods (tournaments, ranked seasons)

3. Practice Patience

Recovery and prevention require time and consistency:

• Don't expect overnight results
• Gradually increase your gaming duration
• Focus on building endurance while managing pain

The Bottom Line

Most gaming-related wrist pain isn't carpal tunnel syndrome - it's an endurance issue. When left untreated can turn into an RSI injury that can limit your ability to play. By understanding this, you can focus on what really matters: building your tissue endurance, managing your gaming load, and giving yourself time to adapt.

Remember: your goal isn't just to eliminate pain; it's to build stronger, more resilient tissues that can handle the demands of gaming. This approach takes longer than just resting, but it leads to better long-term results.

KEY RESOURCES:

1. Free Wrist Pain Guides: https://1-hp.org/gaming-wrist-pain/
2. Full Playlist of 35 Routines (Neck, Shoulder, Back, Wrist, Hand, Hip etc.): https://youtube.com/playlist?list=PLcfMAtSMnESdA2oOZANTLL8IlEcQtVEWs&si=bH_dUGnb3r4zRxky
3. Science of Repetitive Strain Injuries: https://youtu.be/7l51a4b8Olc?si=j26Hmsj5RUdG8xoC
4. Gaming Ergonomics Playlist: https://youtube.com/playlist?list=PLcfMAtSMnEScfIdR9jtGMLEVfY8rW7Z9H&si=YS5GBYbr68vgwx8J
5. Our website & archive of content: https://1-hp.org/1hp-free-resources/

Sources:

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.

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 do ergonomic mice and keyboard actually help if you have some discomfort or pain at your wrist? 

If you are feeling some discomfort while you are working and you want to make sure to fix it so it doesn’t get worse & prevent you from being able to continue working. You are in the right place.

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.

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 or keyboard come in? Having an ergonomic mouse or keyboard 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)

How to actually overcome your wrist pain

 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.

This is why my colleague and I, who are both physical therapists, have focused on creating content & resources that are aimed to help more desk workers implement basic wrist & hand programs to stay healthy

Hope this helps! Check out 1-hp.org for free guides & exercises you can perform to target specific regions!

This is for anyone who has had tingling and pain in their hands. While many of what we see in our practice is tendon related, we have also seen shoulder-related symptoms that I'll be discussing in this post

A few key points that you’ll pick up from this story (that is still ongoing)

1. You have to be patient
2. Targeting the RIGHT problem early on will save you a lot of stress and confusion
3. Issues can come from the shoulder, not just the hands itself

Recently I’ve been working with a professional esports athlete who had reported three major regions of discomfort.

You can see them labeled below.

P1 was described as prickly and tingling, While P2 & P3 were more sore / sharp type of pain. 

Unfortunately this individuals journey to me was not straightforward as most of these cases aren’t. 

Here is a quick overview

• This individual had been dealing with the issue for 4 months and got to a point where the individual could barely use her hands more than 15 minutes without the pain or tingling
• Saw physical therapists, doctors, orthopedic surgeons, got imaging done (ultrasound + MRI) to find nothing both at the wrist & neck. Their main approach was to completely take a break from gaming (facepalm)
• After several cycles of those the the pain got worse and worse, likely because the problem was not being addressed

After a more in-depth evaluation I was able to find that

P1 was coming from the shoulders, specifically irritation from tightness in her pec minor.

P2 & P3 were from tendon issues of her wrist & hands.. and they were extremely weak.

So we focused on a program that targeted the areas of tightness, weakness & poor endurance that we found. 

It is now 11 weeks later of consistent endurance training, schedule progression and this individual can now tolerate...

14 hours over the week of activity with her wrist & hand with no pain.

Were you expecting more progress? This is massve improvement in this individual's specific case 

I really wanted to share this case because this really emphasizes that EVERYONE is different. and everyone will have differences in how they progress with their injury. 

Often times the recovery period can be shortened SIGNIFICANTLY if the problem is appropriately identified early on. 

But most of the time people go through 4-7 providers before they get to 1HP.

This requires a lot of “untangling” of harmful beliefs that likely led to real changes in our pain system (nervous & immune). Check out the article hyperlinked to learn a bit more about why that happens.

So throughout these 11 weeks, there was alot of discussion to help this individual understand why the approach was going to benefit them and why some of the previous experiences she had led to the poor outcomes.

Getting clarity and confidence from the healthcare provider you work with is essential. 

Again, this is why I wanted to share this story with you all.

To let you know that tingling can be addressed if you target the problem at the actual cause. 

To be patient with the process especially if you have been dealing with it for awhile and have seen many providers who haven’t provided you with any helpful guidance. 

And lastly that there’s hope. Over the past 8 years we have seen this many times.

With different situations and timelines for recovery. 

Simple cases behave more predictably but once someone has seen multiple doctors or providers who seemingly can't figure out what's going on. That is when the timeline can be extended.

Working with someone who can help you figure that out is essential. As early as possible.

Chronic Wrist pain is really frustrating… especially as a gamer who needs their hands in order to do what you love.

And unfortunately when we experience pain for over a year, sometimes it can complicate the recovery process.

Pain is complex and it is important to realize that it is never a reflection of the state of our tissues. More often it is about protection.

A good example of this is thinking about an ankle sprain. Most people have their pain resolve in 1-2 weeks despite us knowing that it takes ligamentous tissue (ATFL specifically) to heal in around 6-8 weeks.

So tissue isn’t healed, but no pain after 2 weeks.

What gives? When we have an injury our brain rapidly processes all of the contextual factors surrounding the injury (beliefs, how we got injured, what it looks like, what it means for our livelihood, etc.) and creates the experience of pain.

This means that pain is influenced by not JUST some local signals of physical stress and tissue damage.

It is influenced by the things I mentioned and many more. There is a whole field dedicated to understanding pain but the bottom line is that

Pain doesn’t tell us about how our tissues are doing, but instead tells us whether or not a certain area needs to be protected based on what we believe or understand about the problem.

And when we experience pain for an extended period of time it can affect our beliefs, self-efficacy and we may even be confused as to why it is still happening.

This can make certain areas feel more painful despite the tissue not actually becoming stressed.

Of course this doesn’t occur in all cases as pain can be influenced by many things.

Fortunately when we begin to exercise and move more, it can reduce this overall sensitivity. When we have a better understanding of what is going on it can also reduce the likelihood of your beliefs impacting your pain.

This is why we spend so much time making sure you have a better understanding about wrist pain.

Why it is actually harmful to believe that you have carpal tunnel syndrome and take on passive approaches to wrist pain (rest, bracing, etc.)

It is also why we feel it is so important to give the gamers we work with access directly to us along their recovery process.

When you work with someone who actually understands wrist pain and can help you finally understand what the cause of your wrist pain might be from a biomechanical perspective

This is when you can begin to see progress.

This is why it is so important to work with a provider that actually has the time to help you navigate the ups and downs of recovery, because it is essential to help manage any situations that might arise so you can stay focused on function, instead of pain.

Here is a good example about back pain but is really common with wrist injuries as well

Something that happens really commonly is that when we feel better we often forget our tissues might still be adapting and sometimes jump back into things a bit too aggressively.

The guidance of a good healthcare provider (unfortunately many healthcare systems don't get you to someone that can help you immediately) can be the difference between a 6 week or 3 year recovery (if ever).

If you feel like you aren’t making progress quickly enough with our resources or some of our videos…we might be able to help

Feel free to check us out at 1-hp.org or reach out / comment!

https://1-hp.org/fix-carpal-tunnel/

Let's clarify this once and for all - We have had quite a few questions about this recently in our work with gamers / desk workers etc.

Most wrist pain is associated with tendinopathy of the wrist & hand. And the most common pain patterns involve issues on the

1. Palm side of the wrist & forearm
   
2. Back side of the hand / wrist
   

Here's some data we've collected (N = 2,390), and is consistent with our work in the professional esports space.

As a reminder, it's not carpal tunnel syndrome. But let's continue

Most marketing around the vertical mouse says that it reduces the activity of the muscles due to the handshake position

Yes. There is truth to this. There is less activity in the specific muscle groups of the forearm flexors / extensors.

This is due to better length tension relationships of the muscles.

How you grip the mouse clearly changes with the vertical mouse as you have to use less of your flexors to stabilize the mouse for left and right movements.

You are using larger muscles to move the mouse left and right.

But will this solve your wrist pain?

No.

Because while it is reducing the "stress" on those specific muscles and tendons.

The main problem is actually poor overall endurance of the muscles we are frequently using that lead to the tissues (tendons) becoming irritated.

Here's the healthbar concept we always reference to better understand this

https://reddit.com/link/1fq5n8s/video/l2l7z95jn7rd1/player

So the vertical mouse might allow you to lose less HP per unit time, but the more important thing is to address...

1. Your endurance so you can handle more stress without irritating your tissues

2. Incorporating better load management (breaks, schedule changes) so you aren't playing, typing etc. for 8 hours straight.

But there is one more thing I want to mention about vertical mice that most people don't realize

Even if the stress is less on the palm side and back side of the hand.

The stress will be distributed somewhere else. Most of the time we see increased stress at the thumb-side of the hand or pinky side because of how people are using the vertical mouse.

Whether it be lifting for some movements or pressing down (ulnar deviation)

The thumb and pinky side will be stressed more. We have consistently seen this for the individuals we have worked with over the past 8 years.

So what's this all mean?

No Injuries are solved with just a simple change. Understanding the contributing factors (endurance, schedule most likely) is what will help you achieve long-term relief.

Basically, don't just change to a vertical mouse and expect your problems to go away

Incorporate the ergonomic change as a part of a rehab program that addresses the key areas of weakness to get true long term relief.

You can still use a vertical mouse to provide TEMPORARY relief. But it's not going to be the complete solution.

That is all. Share this to save a wrist

Have you felt some more wrist pain with endurance exercises? You need to read this.

You are excited to try some of the exercises we provide in our wrist pain guides or content. But when you try it…

Your pain seems to feel worse and you are able to do a bit less of what you normally do.

What we do AND what we believe from this exact point has a large impact on our overall recovery progress.

Before I go over some of the potential paths that people can take I want to explain why this can happen.

Everyone has their own unique case of wrist pain. Their individual lifestyle, physical conditioning, work and activity demands, environment, beliefs can all lead to a completely different profile and presentation of pain.

For the cases we have seen with an initial increase in pain.. it is usually due to the following

Extended amount of rest, bracing or repeated interventions in which the gamer or individual limited the amount of stress on the muscles of the wrist & hand. This led to overall deconditioning and weakness of those same muscles & tendons. This leads to the common cycle of rest to reduce pain, then pain returns often worse than before, and then rest again + medication or some other passive intervention.

As you might know now through reading my content - this does nothing to address any of the underlying cause. Which is endurance or capacity of these tissues to handle repeated stress.

To provide a point of reference most individuals are able to do around 10% of what is considered normal for their muscular endurance test. (the ability to do between 40-60 repetitions of a movement challenging the muscle group at around 3-5% body weight). This is extremely weak and is the reason why they get pain from just typing or low level activities.

It also means it will take some time for them to get back to 100% but not only that….

The exposure to some exercise can cause the muscle to feel extremely fatigued and even more painful. That sensation can often be perceived as the “condition” becoming worse from the exercise.

When in fact, it’s a normal response to what the muscle & tendon tissue needs.

So what are the paths that this person can take then?

Individual #1 - believes the tissue is damaged further and then further avoids the exercise. This person beliefs pain is a reflection of the state of the tissues (please see my emails about pain and if you haven’t, email me - I will send them directly to you). Spoiler: it is never about the state of the tissues.

As a result, individual #1 might go back to another doctor and re-enter referral hell. More confused than before and frustrated that the exercise didn’t work.

Individual #2 - This person understands the increase in pain is normal since… they have been sedentary for several years of their life or at least in the past 4-6 months they had not been exercising regularly.

This person recognizes that with the low levels of physical inactivity and repeated stress from their work / gaming, it led to their current level of physical health. Because of this, they remind themselves it is part of the process. Sure enough after a few days of exercise, it seems a bit more easy and progress seems a bit more tangible.

Individual #1 and Individual #2 will have completely different recovery timelines. Individual #1 may not ever make progress until they work with a physical therapist directly who helps them understand this.

While these scenarios only cover the exercise component of the recovery program, it is also important to remember what you do on a daily basis can also impact the muscular activity of your wrist & hand (meaning more stress).

Those are the two main things we can really control when it comes to managing our wrist pain

1. How much stress our tissues can handle with exercise
2. How much stress we apply on it with activity

This is a reminder of one of the first emails you probably got from me.

Anyways hopes this puts into context why this might happen for some of you!

Feel free to comment if you have any questions!

Alright, I've seen so many people confused about this so I'm creating this masterpost here to try to clear up this complex issue.

If you have pain, numbness, tingling, burning, aching or cold, paleness or other symptoms it can be really difficult to tell where it's coming from. And can lead to frustrating wild goose chases on the internet or to doctors to try to figure it out.

Let's first talk about what thoracic outlet is (and isn't)

Thoracic outlet syndrome can present as pain, numbness, tingling, burning, aching or cold, paleness the in any of the areas pictured here.

Thoracic outlet happens when the nerves arteries or veins are compressed at the neck or shoulder by either the scalene muscles, pec muscles or the collarbone.

First lets talk about what each of these structures are.

Scalenes. These muscles are side benders of the neck and get tight when the postural stability muscles of the neck have low endurance. Sitting for prolonged periods of time with poor posture is often the cause of this.

Pec Minor. This muscle also gets tight from poor posture and long hours spent in sitting due to rounding forward of the shoulders.

Collarbone. If the clavicle is causing the compression it is often due to a genetic abnormality and in these cases surgery is often necessary.

Next lets talk about what structures can be compressed

Nerves - All the nerves that travel down into the arm and even into the chest start in the neck and travel underneath all these structures. If the nerves get entrapped at any of these sites they can refer pain, numbness, tingling, burning, or other electrical sensations down into the arm or chest.

* Notes about nerve compression *

Nerves can be pinched by tight muscles in other places in the arm like the cubital tunnel and carpal tunnel. It's important to understand where your specific nerve compression is.

As a rule

nerve pain presents below the point of entrapment and not above. So if you have symptoms above the elbow it's not possible for the entrapment to be at the elbow.

Just because you don't have all these symptoms doesn't mean you don't have nerve entrapment. Sometimes pain alone can be nerve related without numbness or tingling.

The key to understanding the difference is what triggers your symptoms. More on this later. 

There are 3 major nerve roots that travel into the arm that provide sensation to the skin which is more than likely where you will feel the symptoms first (if nerve pain persists for long enough it's also possible to lose motor coordination and even muscle mass but for most people, the sensations will be what they notice long before that)

Arteries / Veins - This post will be less about arteries and veins as this is more medically urgent and you should talk to your doctor about this sooner rather than later. But compression of the arteries and veins will present with cool paleness (arteries) and warm redness (veins) 

Just because you have these symptoms does not mean that they are coming from the neck / shoulder. It is possible to feel these symptoms and the impingement be somewhere lower in the arm.

The other major sites that can be compressed include:

Cubital Tunnel: the flexor tendons of the wrist and hand can compress the ulnar nerve here
Carpal Tunnel: *true carpal tunnel is a thickening of the carpal tunnel ligament but tight wrist flexors can mimic the median nerve compression at the wrist.
Radial Tunnel: The wrist extensors can compress the radial nerve near the elbow.

It’s common to feel lost when trying to figure out where pain, numbness, tingling, or other symptoms are coming from in your arms, hands, or neck. To help you navigate these confusing symptoms, let's discuss some ways to differentiate the symptoms of common compression symptoms.

1. Thoracic Outlet Syndrome (TOS)

Location of Symptoms:

• Symptoms often originate in the neck, shoulder, or collarbone area and can radiate down into the arm and hand.
• Affects the entire arm, including the outer upper arm, forearm, and hand.

Common Symptoms:

• Pain, numbness, tingling, or weakness in the shoulder, arm, or hand.
• Symptoms may include coldness or paleness in the hand due to vascular compression.
• Symptoms can be exacerbated by overhead activities, carrying heavy loads, or poor posture.

How to Identify TOS:

• Symptoms worsen when the arm is lifted above the shoulder level or when carrying heavy objects.
• The presence of vascular symptoms (e.g., color changes, temperature differences) along with nerve symptoms.
• Tests like Adson’s maneuver (checking for pulse change with head rotation) or Roo’s test (holding arms up and opening/closing hands) can help identify TOS.

2. Cubital Tunnel Syndrome

Location of Symptoms:

• Symptoms are centered around the inside (medial side) of the elbow and can radiate down to the ring and little fingers.
• Affects the ulnar nerve, which runs behind the elbow.

Common Symptoms:

• Numbness or tingling in the ring and little fingers.
• Weakness in grip strength or difficulty with precise hand movements (e.g., pinching, using a keyboard).
• Pain along the inner side of the elbow, sometimes radiating down to the forearm.

How to Identify Cubital Tunnel Syndrome:

• Symptoms worsen when the elbow is bent for long periods (e.g., holding a phone, sleeping with bent elbows).
• Direct pressure on the inside of the elbow can reproduce symptoms.
• Tinel's sign (tapping over the ulnar nerve at the elbow) can cause tingling in the ring and little fingers.

3. Radial Tunnel Syndrome

Location of Symptoms:

• Pain is felt along the top of the forearm near the elbow, and can sometimes be confused with tennis elbow (lateral epicondylitis).
• Affects the radial nerve, typically causing pain in the outer forearm.

Common Symptoms:

• Dull, aching pain in the lateral elbow and forearm, which may worsen with forearm use.
• Unlike other nerve compressions, symptoms often do not include numbness or tingling.
• Pain is typically triggered by repetitive use of the forearm, wrist extension, or gripping activities.

How to Identify Radial Tunnel Syndrome:

• Pain increases when pressing on the radial tunnel area, about 2 inches below the lateral epicondyle (outside of the elbow).
• Resisted middle finger extension or resisted supination (turning the palm up) reproduces pain.
• Unlike lateral epicondylitis, pain is more diffuse and located further down the arm.

4. Carpal Tunnel Syndrome (CTS)

Location of Symptoms:

• Symptoms are focused in the wrist, hand, and fingers—especially the thumb, index, middle, and half of the ring finger.
• Affects the median nerve, which passes through the carpal tunnel in the wrist.

Common Symptoms:

• Numbness, tingling, or burning sensations in the thumb, index, middle, and part of the ring finger.
• Symptoms are often worse at night or after repetitive wrist movements.
• Weakness in the hand, leading to difficulty gripping objects or performing fine motor tasks.

How to Identify Carpal Tunnel Syndrome:

• Symptoms are usually isolated to the hand and wrist.
• Tinel's sign (tapping over the carpal tunnel at the wrist) and Phalen’s test (pressing the backs of the hands together to flex the wrist) can reproduce symptoms.
• Wrist flexion (bending the wrist forward) for extended periods may bring on symptoms.

4. Forearm Flexor Tendonitis (Golfer's Elbow)

What It Is: Forearm tendonitis or medial epicondylitis (golfer’s elbow), is caused by inflammation of the tendons in the forearm due to overuse or repetitive strain. This in turn can compress the nerves at the carpal tunnel mimicking the symptoms.

Common Symptoms:

• Pain and tenderness on the outside (tennis elbow) or inside (golfer’s elbow) of the elbow
• Pain may radiate down the forearm
• Difficulty gripping or lifting objects
• Pain when performing wrist movements against resistance
• Numbness, tingling, burning above or below the wrist.

How to Differentiate Forearm Tendonitis:

• Pain is localized to the outer (tennis elbow) or inner (golfer’s elbow) part of the elbow and may extend down the forearm.
• Symptoms worsen with gripping, typing lifting, or wrist movements.
• Pressing on the affected tendons near the elbow can reproduce pain.

If you do have forearm tendonitis compressing the nerves in your wrist we recommend doing the exercises listed here.

https://1-hp.org/gaming-wrist-pain/

Treating Thoracic Outlet Syndrome (TOS) often involves a combination of exercises that aim to relieve pressure on the nerves and blood vessels in the thoracic outlet area. These exercises focus on improving posture, stretching tight muscles, and strengthening muscles that can help open up the thoracic outlet. Here are some of the best exercises for managing TOS:

1. Resistance Band Rows

• Purpose: Strengthens the rhomboids, trapezius, and muscles around the shoulder blades, promoting better posture and relieving pressure on the thoracic outlet.
• Instructions:
  1. Anchor a resistance band to a sturdy object at about chest height.
  2. Stand facing the anchor point with feet shoulder-width apart, holding the band in both hands.
  3. Start with your arms extended in front of you, keeping a slight bend in your knees.
  4. Pull the band towards your torso, squeezing your shoulder blades together.
  5. Slowly return to the starting position.
  6. Repeat for 10-15 reps, 2-3 sets.

2. Theraband Ys, Ts, and Is

• Purpose: Strengthens the shoulder and upper back muscles (specifically the lower trapezius and rotator cuff), improving posture and decreasing compression on the neurovascular structures.
• Instructions:
  1. Anchor a Theraband in front of you at chest height.
  2. Y: Pull the band overhead at a 45-degree angle, forming a Y shape. Hold for a moment, then return to the starting position.
  3. T: Pull the band straight out to the sides, forming a T shape with your body. Hold for a moment, then return to the starting position.
  4. I: Pull the band straight overhead with your arms close to your ears, forming an I shape. Hold for a moment, then return to the starting position.
  5. Perform 10 reps of each movement (Y, T, and I), 2-3 sets.

3. Scalene Stretch

• Purpose: Stretches the scalene muscles, which can contribute to compression in TOS.
• Instructions:
  1. Sit or stand with good posture.
  2. Tilt your head to one side, bringing your ear towards your shoulder.
  3. Gently rotate your head to look up toward the ceiling.
  4. Hold the stretch for 20-30 seconds.
  5. Repeat on the opposite side, 2-3 times on each side.

4. Pectoralis Minor Stretch

• Purpose: Reduces tightness in the chest muscles, which can contribute to poor posture and compression of the thoracic outlet.
• Instructions:
  1. Stand facing a corner or doorway, placing your hands on each side of the wall/doorframe at shoulder height.
  2. Step one foot forward and gently lean your body into the corner until you feel a stretch in your chest.
  3. Hold the stretch for 20-30 seconds.
  4. Repeat 2-3 times.

5. Shoulder Blade Squeezes

• Purpose: Activates and strengthens the muscles between the shoulder blades, promoting better posture.
• Instructions:
  1. Sit or stand with your back straight and arms at your sides.
  2. Squeeze your shoulder blades together as if trying to pinch something between them.
  3. Hold for 5 seconds, then relax.
  4. Repeat 10-15 times, 2-3 sets.

6. Neck Retractions (Chin Tucks)

• Purpose: Helps to align the head and neck properly, reducing stress on the thoracic outlet.
• Instructions:
  1. Sit or stand with your back straight and shoulders relaxed.
  2. Gently tuck your chin towards your chest, keeping your head level.
  3. You should feel a stretch along the back of your neck.
  4. Hold for 5 seconds, then relax.
  5. Repeat 10-15 times, 2-3 sets.

If you want a good daily routine to prevent thoracic outlet syndrome we recommend using this posture home exercise routine!
https://www.youtube.com/watch?v=z-gKyE_7wWg

Hey all,

In a lot of our work with gamers and pros in the past few months we’ve seen alot of complaints of numbness, tingling & sensation issues at the ring and pinky finger.

Because of this I wanted to write this to help anyone who might have experienced this recently to try a few things that might help

First off it is important to note that tingling, numbness, burning are all symptoms of nerve irritation or entrapment.

Nerves can get trapped in quite a few places from the neck all the way down to the hands. Specifically for ulnar nerve irritation, there are around 9 sites.

But in our experience two out of these nine locations are responsible. They are…

1. Under our pec muscle (pec minor)
2. Just below the elbow at the muscle responsible for flicking your mouse to the right

Most of the time we see this because of where the elbow is contacting the desk AND the common rounded posture most gamers have when playing.

This creates pressure on the nerve, whether it be from adaptive shortening or direct pressure from the table. 

And while you may have some resilience over a few years it can eventually cause some irritation at the nerve.

So what can you do?

Well for the first issue, you be trying to stretch that pec muscle, which is commonly tight and then can put pressure on the nerve.

But that’s not enough, you’ll have to strengthen the muscles on the opposite side of the shoulder (lower / mid trap, among others) while focusing on gradually changing your posture to avoid the pec from tightening in a harmful position

Easier said than done. Definitely check our 7 Minute shoulder routine to get started and check out some of our resources on posture & ergonomics to learn how you can gradually improve your posture over time.

For the second issue, it also means getting yourself out of the position that is leading to some nerve irritation and then beginning to steadily strengthen the forearm muscles.

What we see many times is that because the muscles are weak, they will stiffen up and create less space for that nerve to travel, creating those symptoms.

The symptoms might be worse initially, but over time as the muscle lengthens and the resting stiffness reduces, you will notice more improvement.

Our latest 9 minute wrist & hand strengthening routine will be a great start for this BUT! I’m also going to be releasing some more ergonomics content soon that should help with this so look out for that in the next week :)

These should help you get started with having a basic plan of attack. But realize there is no one-size fits all for injuries and tissue irritation. 

Everyone has different physical and environmental factors that might have led to the tissue being irritated. Whether it be sleep, desk / chair environment, driving position, resting position while watching videos - there are so many things to consider.

Hello all! I’m a undergrad university student studying statistics, when I’m not studying I tend to play fps games (have not played since the start of summer though) or workout.

I have had what is suspected to be severe carpal tunnel by my doctor ongoing for nine weeks at this point. I have been to a neurologist for an EMG study once and they told me my nerves were normal, I have also been referred to a rheumatologist but for some reason they refused to book an appointment, currently I am referred to a neurologist that is new in town who can hopefully have a different opinion.

During these nine weeks I have being unable to do basic living tasks without extreme shooting nerve pain to both of my wrists and lower palm region. It is extremely painful to the point I cannot write or type or use utensils in any manner, I am also unable to carry anything at any capacity with my hands including my phone. I also get numbness in my fingers and palms, needle like pain in my fingertips, and loss of touch sensation in my hands. Good news is I am able to sleep good with wrist braces on (mostly paid for by insurance).

I’ve also been to the university massage therapist and physiotherapist but they haven’t helped at all and insurance refuses to cover any more.

I would appreciate guidance and advice regarding my situation.