The most well known injury in gaming is carpal tunnel. This perception by the general public shows that there is a distinct lack of understanding about what causes gaming injuries and what structures are involved. Carpal tunnel is effectively a compression of the median nerve. In this article we will be exploring the different nerves that can be impacted in gaming and discuss how relevant each is.

Nerves act as the body’s relay system as they carry electrical impulses throughout the body where they are able to transmit both motor and sensory information between the brain and the rest of your body.

Nerves are ubiquitous throughout the body and are likely something we take for granted until they are not working properly. Nerve irritation can be most easily identified by burning, numbness, tingling, and/or weakness throughout specific areas of the body. There are two main types of nerves throughout our body: sensory nerves which carry signals to the brain regarding touch and sensation and motor nerves which carry signals to the muscles to cause the contractions that bring about motion at the joints.

Precise and complex hand motions, like holding, pinching, gripping, and manipulating, are common in everyday activities. Gamers rely even more so on the use of their hands for control over mice, keyboards, and controllers. Nerve dysfunction and/or pain is something most players dread and can result in significant negative impacts on performance. However, for medical and performance professionals within the esports industry, it is important to know and understand the basics of what to look for, how to avoid nerve irritation, how to test for it, and what can be done to help.

Note: With regards to diagnosis, assessment, and intervention, ONLY apply this knowledge within appropriate scope of practice for your profession.

While these conditions are discussed more in-depth in our Medical course, this content access pass article will provide a very brief overview of how the nerves of the hand function.

Median Nerve

Provides innervation to the thumb, index finger, middle finger, and the radial half of the ring finger on the volar side as well as the dorsal aspect of the same fingers discussed, but only distal to the proximal interphalangeal joint (PIP).

Entrapment of the median nerve is the most common nerve entrapment in the upper extremity, but it is certainly not the only nerve that can become irritated. However, just because it’s the most common doesn’t mean it’s the ONLY nerve involved. A common error, even among medical professionals, is to start from the assumption that hand, wrist, or finger pain is attributable to carpal tunnel syndrome.  Carpal tunnel syndrome has specific symptoms and can be assessed both with imaging and clinical testing.

In this article, we discuss carpal tunnel syndrome first not because it is the most common wrist gaming injury, but because it is most commonly assumed to be. Other clinical conditions can cause similar symptoms, and will also be reviewed.

Carpal Tunnel Syndrome:

Carpal tunnel syndrome (CTS) is an injury that affects the hand and wrist. The carpal tunnel is a narrow space within the wrist which allows nine tendons and the median nerve to pass through. Irritation of this median nerve is brought on by a variety of factors such as repetitive use or gripping, swelling in the arm/hand, an injury, fluid retention from pregnancy, using vibrating tools, extreme flexion/extension of the wrist, putting pressure over the carpal tunnel, and exposure to cold temperature. Carpal tunnel syndrome can present with paresthesia as well as pain throughout the median nerve distribution. Age, gender, occupation, and anatomy can also play a factor as women are 3x more likely to suffer from CTS than men.

As described above, CTS is the most well-known upper extremity injury, but that does not mean that any arm, wrist, hand, or finger pain is CTS. In fact, preliminary data suggest tendinopathies as being a far more prevalent condition than CTS (Hwu, 2021). When it occurs, CTS is brought on by a variety of factors, including a lack of rest breaks (Feng et al., 2021), overweight/obesity (Shiri et al., 2015), wrist angle, repetitive gripping, increased swelling of the hand/wrist, sleep positioning, anthropometric measures, use of vibrating tools, and cold temperature. Women are often known to be 3x more prone to developing CTS, but when strictly looking at the occupation of data entry there was no significant change which for gamers may be the most practical comparison (McDiarmid et al., 2000). Gamers in particular should be aware of maintaining a neutral wrist or small wrist extension angle when using a mouse, setting rest breaks every 30 min, and monitoring their sleeping position so as to not have wrists excessively bent.

Other Median Nerve Injuries

Pronator Teres Syndrome:

Pronator teres syndrome is a median nerve compression occurring near the elbow that often gets overlooked or even misdiagnosed as CTS. The pronator teres muscle is located within the anterior forearm where it originates at the medial epicondyle and coronoid process of the ulna and inserts on the radius. This muscle pronates the forearm, rotating the palm downwards. Similar to CTS, pronator teres syndrome may come on from repetitive grasping, but it is common with repetitive pronation movements as well.

Anterior interosseous nerve syndrome:

Anterior interosseous nerve syndrome is a condition which results in pain on the anterior side of the proximal forearm. This is a compression of the motor nerve which would result in weakness for pinching and gripping and reducing overall dexterity and performance. This is unlikely to be a common gaming injury, but may be relevant when treating individuals who have pain that occurs WHILE gaming if they have another potential mechanism of injury.

Provocative testing is done to reproduce symptoms and help rule in or rule out certain injuries as the most likely cause of the issue.

• Tinel’s Test (Carpal Tunnel):

  • Tapping or light percussion done over the carpal tunnel at the wrist. The test is positive if it elicits paresthesia in the median nerve distribution.

• Phalen’s Maneuver:

  • Place the wrists in full flexion and hold for 60 seconds. The test is positive if it elicits paresthesia or tingling/numbness in the median nerve distribution.

• Durkan’s (Compression) Test:

  • This test is performed by putting pressure over the carpal tunnel for 30 seconds. The test is positive if it elicits paresthesia in the median nerve distribution.

• Median Nerve Tension Test:

  • This test is performed with the help of a clinician who will take each arm through a set of motions where the nerve becomes stretched or tensioned. This tension may provoke symptoms, but can reveal differences between the contralateral side giving notice to the clinician of possible nerve irritation or compression.

These are the tests an occupational therapist, physical therapist, or medical doctor are likely to do as part of an evaluation for hand and wrist pain. These tests should only be performed and interpreted by a qualified medical professional.

Treatment will and should vary from person to person, in large part based on what clinical testing reveals as the source of the symptoms. Potential interventions include nerve glides, tendon glides, stretches, strength and endurance exercises, activity modification, and splinting.

Radial Nerve

The radial nerve divides into two branches: the superficial branch and the deep branch. The superficial branch provides innervation to the dorsal side of the thumb, Index, middle, and the radial half of the ring finger just proximal to the IP joints as well as a small portion of the volar side of the thumb where it gives sensation. The deep branch or posterior interosseous nerve (PIN) is a motor branch which gives input to the supinator muscle as well as extensors of the wrist and digits.

Radial Tunnel Syndrome

Radial tunnel syndrome is a compression of the PIN where it passes through muscles on the posterior side of the forearm. This nerve irritation is often a result of everyone’s least favorite arcade, the arcade of Frohse which is an anatomical location on the proximal aspect of the supinator muscle. This injury can arise from repetitive use especially in activities that require forearm pronation/supination in combination with elbow extension, wrist extension, and gripping. This nerve compression often only presents as an achy pain, but does not cause numbness/tingling as the PIN is a motor nerve, not a sensory nerve and therefore can be easily mistaken for a diagnosis of tennis elbow or lateral epicondylosis due to the location of the pain being close in relation to each other.

Wartenberg syndrome

Wartenberg syndrome is compression of the superficial branch of the radial nerve, resulting in sensory issues. This will present as pain over the dorsal aspect of the distal forearm and paresthesia throughout the radial nerve distribution of the hand. This may present from wearing a watch, bracelet, or wristband around the wrist which may arise with the use of gaming gloves as a possible issue. It is also important to note that Wartenberg syndrome and Wartenberg’s sign are two distinctly different things.

Differential diagnosis to look out for may be intersection syndrome or DeQuervian’s tenosynovitis as pain presents in close proximity to where pain arises from Wartenberg’s Syndrome.

Provocative Testing: Provocative testing is done to reproduce the symptoms you are describing and help clinicians make judgments as to what condition you’re experiencing.

• Radial Nerve Tension Test:

  • This test is performed with the help of a clinician who will take each arm through a set of motions where the nerve becomes stretched or tensioned. This tension may provoke symptoms, but can reveal differences between the contralateral side giving notice to the clinician of possible nerve irritation or compression.

• Radial Nerve Palpation

  • Tapping or light percussion done over the posterior proximal forearm over the radial tunnel. The test is positive if pain is present

These are the tests an occupational therapist, physical therapist, or medical doctor are likely to do as part of an evaluation for hand and wrist pain. These tests should only be performed and interpreted by a qualified medical professional.

Treatment will and should vary from person to person, in large part based on what clinical testing reveals as the source of the symptoms. Potential interventions include nerve glides, tendon glides, stretches, strength and endurance exercises, activity modification, and splinting.

Ulnar Nerve

The ulnar nerve provides innervation to the small finger and ulnar side of the ring finger both on the volar and dorsal side.

Cubital Tunnel Syndrome

Cubital tunnel syndrome is a condition that affects the ulnar nerve distribution of your hand resulting in numbness, tingling, and/or burning. This condition happens due to compression or irritation of your ulnar nerve at your elbow. This can be caused due to prolonged elbow flexion such as talking on the phone, sleeping with your elbows bent, etc. It can also be caused by repetitive bending and straightening of the elbow, a traumatic injury, or even by putting pressure or resting the elbow on a desk, table, armrest, etc. Cubital tunnel syndrome is the second most common nerve compression in the arm and is likely more well known as your “funny bone” as the ulnar nerve is what is being hit and sending that sharp pain or zing throughout your arm.

Guyon’s Canal Syndrome

Guyon’s Canal Syndrome is a condition where the ulnar nerve is compressed near the volar wrist in the hypothenar eminence in a space called Guyon’s Canal. This space is adjacent to the carpal tunnel. This compression may present with motor or sensory involvement or a combination of both depending on where the compression takes place on the nerve.

Provocative Testing: Provocative testing is done to reproduce the symptoms you are describing and help clinicians make judgments as to what condition you’re experiencing.

• Tinels (Cubital tunnel)

  • Tapping or light percussion done over the ulnar nerve at the elbow. The test is positive if it elicits paresthesia in the ulnar nerve distribution.

• Tinels (Guyon’s Canal)

  • Tapping or light percussion done over the ulnar nerve throughout the hypothenar eminence at the hand/wrist. The test is positive if it elicits paresthesia in the ulnar nerve distribution.

• Elbow Flexion Test (Cubital Tunnel Syndrome)

  • Have the patient fully flex their elbow and extend their wrists and hold it for 1-3 minutes. A positive sign is paresthesia throughout the ulnar nerve distribution of your hand.

• Froment’s Sign

  • The patient will perform a lateral pinch using a flat object such as a piece of paper between the thumb and index finger. A positive sign is flexion of the thumb IP joint to compensate for weakness of the adductor pollicis due to ulnar nerve palsy.

• Wartenberg’s Sign

  • The patient will extend all the fingers on a flat surface with the wrist in a neutral position, then they will abduct and adduct the fingers. A positive test is the inability to adduct the small finger and indicates ulnar nerve neuropathy, but does not determine site of compression. This should not be confused with Wartenberg’s Syndrome.

• Ulnar Nerve Tension Test

  • This test is performed with the help of a clinician who will take each arm through a set of motions where the nerve becomes stretched or tensioned. This tension may provoke symptoms, but can reveal differences between the contralateral side giving notice to the clinician of possible nerve irritation or compression.

Thoracic Outlet Syndrome (TOS) is another condition which should be assessed as the nerves discussed above all stem from something called the brachial plexus. The brachial plexus is a network of nerves that come off of the spinal cord and travel between the clavicle and the first rib down into the arm. The presentation, treatment, provocative testing, and causes,  regarding TOS will be covered in future articles, but for now it is worth mentioning as this could lead to confusion when interpreting pain or sensory disturbances throughout the arm, wrist, hand, fingers while it may be a result of entrapment further up the chain near the neck.