Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a contentious topic in eSports and gaming. While extensive research into this topic has yet to be conducted, there have been instances where competitive gamers have had to give up their career due to CTS. It is well documented, however, that CTS is a common repetitive strain injury (RSI).

In order to understand CTS and how it occurs, a small anatomy lesson is required.

There are nine tendons and one nerve that run through the carpal tunnel. The median nerve supplies motor function for the muscles of the forearm and thenar muscles of the hand. It also provides sensory innervation to the palm of the hand and the tips of the first to third fingers and one half of the fourth finger.

The CTS is the entrapment of the median nerve within the carpal tunnel which is located in the wrist (Katirji, 2016). Essentially, what this means is that there is compression of the median nerve due to inflammation, which causes CTS.

Symptoms of CTS (Othobullets, 2020):

  • Numbness and tingling in radial 3-1/2 digits
  • Clumsiness
  • Pain and paraesthesia that awaken person at night
  • Intense temperature sensations
  • Exacerbation of symptoms with repetitive actions or sustained grip

The sensory symptoms occur first, with motor symptoms being late signs of CTS.

How to Diagnose CTS (Viera, 2003):

A combination of history from the patients and electromyography are used to diagnose CTS. The following tests are done to confirm diagnosis

  • Tinel’s Test – tapping on the wrist causes parasthesia and pain in the fingers supplied by the median nerve
  • Phalen’s Test – forced flexion of the wrist (like a prayer motion) provokes symptoms
  • Flick Test – Shaking the hand causes temporary relief of symptoms

How is this related to gaming?

The prolonged extension and flexion of the wrist (as one does in gaming) causes pressure on the median nerve. This prolonged pressure to the wrist causes physiological and mechanical changes, attributing to the slowing down of nerve conduction along the median nerve. Motions and postures resulting in prolonged compression of the carpal tunnel predisposes to the development of CTS.

While studies have discredited the link between frequent occupational typing and CTS, the high-intensity, long hours and fast paced hand movements often associated in PC-related eSports have shown more wrist extension and flexion.

Repetitive clinking on the mouse can cause an increase in pressure in the carpal tunnel, through the inflammation of the tendons the run from the clicking fingers to the wrist.

The way that gamers rest their hands on the mouse and keyboard are dependent on the type of game they are playing and the control layout. WASD and claw grip (as pictured below) is associated with more wrist extension, as opposed to a standard mouse grip and QWER hand placement. Players using these layouts may be more at risk of developing CTS, however, extensive scientific research needs to be conducted in order to confirm these claims.

Standard Mouse grip, with fingers relaxing fully on the buttons. Wrist is in neutral position.
QWER keyboard hand and wrist placement. The similar level at which the fingers rest on keys a low for an almost neutral wrist placement.

Claw Mouse grip, where the tips of the fingers rest on the buttons. Wrist is in slight extension in this position.
WASD keyboard hand ans wrist placement. The differing levels at which fingers must rest causes the hand to assume a more claw-like position, pushing the wrist into slight flexion.

Kurtis “Toyz” Wai-kin of Taipei Assassins and Lam Du “Hai” Hai of Cloud9 are two retired League of Legends eSports gamers who were forced into early retirement due to carpal tunnel syndrome, stating that their injuries keep them from playing for long periods of time, making it difficult to keep up in the competitive scene, where playing more than 10 hours a day is the norm.

Treatment Options

Treatment for CTS is split into non-operative and operative management. The non-operative management includes pain medications, splinting the wrist, avoiding aggravating activity and steroid injections. Of these, approximately 80% have transient improvement in their symptoms (OrthoBullets, 2020). Operative management is considered in the event of failing non-operative measurements and includes carpal tunnel release surgery, which only has a 25% complete success rate. CTR surgery also has a recovery period of approximately 3 – 4 months, where no aggravating activities can be done. For eSports gamers, this can mean the end of their career.

CTS is an interesting topic, with not much scientific evidence. It would be beneficial to follow a cohort of gamers over a period of time to gauge the probability of developing CTS.