Beyond Tissue Damage: A Case Study on Chronic Wrist Pain & Central Sensitization in Gamers

Many gamers experiencing persistent discomfort often find themselves asking: 'I've tried exercises and worked with physical therapists, so why does my pain still linger?' The answer, as we often discover at 1HP, extends beyond simple tissue damage. Your pain experience is complex, influenced by a myriad of factors, including the fascinating phenomenon of central sensitization.

Imagine living with chronic wrist pain that defies conventional explanation – pain that no standard test or scan can fully account for. This was the reality for LR, a competitive gamer and student, when he first sought our help. His pain with gaming and clicking was inconsistent with his current physical conditioning, pointing towards a deeper, more intricate issue: central sensitization.

Over four months, we guided LR through a comprehensive program designed to address underlying physical deficits, cultivate a deeper understanding of pain science, and ultimately, rebuild his relationship with his pain and beloved gaming activities. This journey highlights a common challenge faced by many in the gaming community. Often, individuals encounter healthcare providers who, despite their best intentions, may not be fully updated on the latest evidence-based approaches to treating wrist and hand injuries, especially those prevalent in esports.

This can lead to an over-reliance on passive interventions like bracing, rest, or medication, fostering a belief that one has little control over their injury. The cycle of temporary relief followed by a return of pain upon resuming activity can breed fear, anxiety, and the harmful conviction that surgery is the only recourse, or even that the pain will be a permanent fixture in one's life.

We want to assure you that this doesn't have to be your future. By collaborating closely with a provider who deeply understands pain science and the advancements made over the past decade, you can develop a healthier relationship with your pain and reclaim your active lifestyle.

Before delving into LR's specific case, it's important to note my background as a Physical Therapist specializing in wrist and hand issues for the past decade. I've had the privilege of speaking at medical conferences, publishing studies, and contributing chapters to textbooks on this very subject.

Wrist and hand pain often begins as an irritation of tendons or muscles. When managed appropriately, these acute cases can frequently resolve within a few weeks. However, proper management of upper extremity Repetitive Strain Injuries (RSIs) is unfortunately rare within our current healthcare system (as detailed in our megathread), often paving the way for the development of chronic pain.

Throughout this case study, I will integrate current research on central sensitization. For a more in-depth exploration, you can also refer to a previous article I've posted on the topic.

Let's dive into LR's journey.

Chronic Wrist Pain with Gaming & Typing: Tendons or Brain?

LR initially contacted us due to pain on the palm side of his wrist and forearm. His reported pain region was consistent with flexor tendon irritation.

Initial Presentation and Contributing Factors

• Occupation: Student, Competitive Gamer
• Symptoms: Dull to moderate pain on the palm side of the wrist extending into the forearm. Typically occurred after 30 minutes of constant mouse tension (e.g., playing Valorant or Aim Labs). Pain would completely subside after a week, but rest alone offered no lasting relief. Pain rated 2/10 at rest, escalating to 4-5/10 after a few hours of activity.
• Medical History: Diagnosed in 2021 with undifferentiated enthesitis-related spondyloarthropathy, which he reported was well-controlled with medication and eccentric exercises.
• Affected Activities:
  • Any activity involving wrist and hand tension caused mild aching.
  • Three games of Valorant resulted in 4-5/10 aching, taking 5-10 minutes to reduce to 2/10, with pain lasting a week.
  • Playing mobile games (Brawl Stars) for 30 minutes caused 3-4/10 pain.
  • Five minutes of aim training caused 4-5/10 pain.
• Perceived Relief: Resting and avoiding wrist-intensive activities seemed to be the only effective strategies for temporary pain alleviation.

Other Important Factors

• Previous Diagnosis & Beliefs: His history with enthesitis significantly influenced his perception of his current pain.
• Personality: A self-described perfectionist, detail-oriented, with a propensity for overthinking and obsessing over specific details.
• Current Exercise Routine: Actively exercising at the gym four times a week (upper/lower split), already incorporating 3x8 pronation/supination and wrist flexion & extension curls.

LR's primary goal was to return to pain-free, wrist-intensive gaming, particularly aim training.

Persistent Chronic Wrist Pain Can Be Shaped by Beliefs and Focus

Our initial evaluation suggested LR was dealing with what appeared to be a straightforward flexor tendinopathy in his right hand. This typically involves the tendons responsible for bending the fingers and wrist downwards (flexion). When these tendons lack the capacity or endurance to withstand the repeated stresses of typing, clicking, or mouse gripping, irritation can occur.

LR's increased engagement in higher-intensity clicking activities, such as aim training and specific Valorant game modes, likely irritated these tendons. As a student, his overall PC usage was high, averaging 7 hours daily. It was a combination of his lifestyle, current physical conditioning, and the surge in gaming activity that likely led to the initial tissue irritation.

For those unfamiliar, aim training is a dedicated practice to improve mouse control and aiming precision in shooter games.

However, a complicating factor emerged that extended what I initially anticipated as a 6-8 week rehabilitation course into a 16-week journey: LR's personality type and his tendency to overthink and obsess over specific details of his condition. While not solely his 'fault,' this aspect played a crucial role, which I'll elaborate on throughout this case study.

Thought Patterns and Their Impact on Physiology

Our initial phase of work focused on addressing the identified endurance deficits. The latter and more significant portion of his recovery centered on tackling his beliefs and mental habits that contributed to his centrally sensitized pain.

We conducted a remote evaluation to pinpoint the contributing factors. The case evolved, so I'll present details from Week 0, Week 8, and Week 16.

Palm-Sided Chronic Wrist Pain with Gaming: Early Issues (Week 0)

• Source of Pain: Flexor Digitorum Profundus & Superficialis Tendons
• Cause of Pain:
  • Sedentary Lifestyle: Prolonged sitting as a student and gamer without regular breaks.
  • Poor Endurance of Forearm Musculature: Lack of specific training to build forearm muscle endurance.
  • Poor Management of Higher-Intensity Gaming: Rapid increase in aim training without appropriate rest or gradual progression.
• Specific Muscle Endurance Testing:
  • Right (R) Hand: 50% of what is considered normal.
  • Left (L) Hand: Within normal limits.
• Daily Schedule:
  • 3 hours of gaming.
  • 5 hours of PC use for school and studying.

As mentioned, clear deficits in his forearm musculature were identified, contributing to tendon irritation and his chronic wrist pain. Based on this assessment, we developed a tailored program to address the lack of endurance and implement relevant modifications for his gaming and lifestyle.

(Please remember, this specific program was designed for LR based on his individual assessment. While it can offer general insights for wrist/hand prevention and management, it's crucial to consult a Physical Therapist for a personalized diagnosis and treatment plan.)

Palm-Sided Chronic Wrist Pain with Gaming: The Impact of Thoughts (Week 8)

Over the initial four weeks, LR made gradual progress in both function and exercise tolerance. He began exercises with a 5lb weight, performing 3 sets of 15-20 repetitions twice daily. During this phase, we also integrated dead hangs into his gym routine 1-2 times per week, where he achieved 45-second holds for 2-3 sets – a significant endurance metric.

His ability to play more physically intensive game modes in Valorant (deathmatch) improved from 1-2 rounds with 5/10 pain to 5-6 rounds with no issues. This progress instilled confidence in both of us to reintroduce aim training into his program.

For context, certain aim training scenarios are more physically demanding. I reviewed his plan and provided specific recommendations on the frequency and duration of these scenarios, allowing for a measured and intentional return to aim training. The initial target was 10 minutes, up from his previous tolerance of 5 minutes. Given his consistent exercise and increased tolerance in Valorant, I was confident he could handle this.

Unfortunately, his response to this attempt was not positive, leading to a mild flare-up.

It's crucial to pause here and emphasize the significance of this moment in any recovery process, especially when returning to desired activities. It is entirely NORMAL to experience flare-ups as you test your capacity to handle higher activity levels (whether it's running, playing an instrument, typing, or gaming). How you respond to these flare-ups is paramount.

When individuals catastrophize, believe the issue hasn't 'healed,' or harbor other harmful beliefs, pain can often intensify and delay recovery. (1-5) This is precisely what happened with LR after this flare-up.

In subsequent visits, LR expressed increased concern over the flare-ups and developed a fear of continuing any activity. He also continued to associate his pain with his previous diagnosis of undifferentiated enthesitis-related spondyloarthropathy, noting a limited work-up from his rheumatologist who had described his issues as 'abnormal' and suggested 'low-stakes drugs.'

This situation was a clear example of how the healthcare system can inadvertently create potentially harmful beliefs for patients. As an overthinker, LR researched his diagnosis, leading to fears about using his wrist and hand based on limited online resources concerning this diagnosis and wrist/hand issues.

It required extensive pain science education, explaining how our clinical exam findings were more consistent with a straightforward tendon problem rather than an underlying medical issue, especially since medical issues had been ruled out through testing.

This discussion led to his request for imaging, culminating in an MRI. I've previously written in depth about how imaging results alone cannot provide a diagnosis and how to best utilize them for RSI issues, which you can read here.

His MRI revealed a minor partial tear in the dorsal band of the scapholunate ligament (SLL) on the top of his wrist. This ligament connects two carpal bones and is primarily stressed during weight-bearing activities (like push-ups) or extreme wrist flexion.

This finding further fueled LR's fears of wrist instability. He conducted his own research, even finding an article recommending surgery for instability (though it referenced a ligament on the opposite side of the hand). I continue to highlight the development of fear because addressing it required me to educate him and provide compelling evidence as to why this partial tear was not a concern:

• He could perform full weight-bearing activities and heavy bench presses without pain.
• His pain was on the palm side of his wrist, opposite the ligament's location.
• No pain occurred even when stressing the ligament with full flexion.
• Small, repetitive, low-load wrist and hand activities, typical of gaming, do not significantly stress this specific joint.

Through a longer conversation, active listening, and patience, LR understood and committed to continuing his program, recognizing that the ligament tear was likely a normal, age-related change rather than the source of his chronic wrist pain.

How We Process and Interpret the Threat of Pain Impacts Behavior and Recovery

Over the subsequent weeks, LR remained consistent with his program, supported by weekly reminders and ongoing pain science education. He needed consistent reinforcement to focus on his endurance improvements and to understand that increases in pain were often associated with a 'fear protection' response from his nervous system.

I achieved this by reviewing his performance results and collaboratively developing specific daily plans to gradually increase his gaming and aim training capacity.

What Happened Over the Next 8 Weeks?

Fixing Chronic Wrist Pain: Pain Science Education is Key (Week 16)

From weeks 8 to 16, we continued our weekly sessions, addressing any concerns as he progressed through his exercises and functional goals. Despite mild flare-ups, LR remained consistent, trusting the pain science and tendon-based approach.

By week 16, he reported being completely pain-free across all activities, fully resuming gaming, student-related work, and other wrist and hand activities. LR achieved normal endurance levels for his right wrist and hand by the 9-week mark, which bolstered my confidence in gradually increasing his function while primarily focusing on deepening his understanding of pain.

During the latter 8 weeks, LR mentioned that he was continually able to remind himself that most of his pain was 'not real' in the sense of ongoing tissue damage, but rather originated from his nervous system being overly sensitive. This continuous self-reassurance during moments of pain and flare-ups ultimately led to the full resolution of his chronic wrist pain.

Achieving this level of understanding and self-management is not easy. Why? Because any injury presents a multitude of situations and scenarios that can influence pain, create fear, and challenge existing pain beliefs. How you think and respond in these situations directly impacts your path to recovery.

Often, this outcome reflects the effectiveness of your healthcare provider in helping you understand pain biology and supporting your self-efficacy. To be transparent, it's challenging to navigate this journey alone. It demands significant patience and trust in a process that takes time.

Pain Tells You About Protection, Not Just Tissue State

Pain is a complex experience. It's the culmination of how you process the context and information surrounding an injury or problem. While pain signals (nociceptors) from your body are one piece of the puzzle, many other sources of information contribute. Your understanding of the injury, past experiences, stress levels, immune system, and contextual factors all provide signals that can profoundly affect your pain experience.

One of the most famous anecdotes, referenced in the British Medical Journal in 1995, helps illustrate this concept: 'The Nail in Boot Guy.' A 29-year-old builder arrived at the ER after jumping onto a 15cm nail. Every minor movement was excruciating, requiring fentanyl and midazolam for sedation. The nail was then removed from below, and upon removing his boot, he was instantly cured – the nail had passed between his toes, leaving his foot entirely uninjured. This highlights how pain can be generated from an 'exaggeration' or 'catastrophizing' by the mind.

This anecdote marked a turning point in our understanding of pain, which has expanded significantly since then. We now recognize the critical importance of understanding pain science and adopting a more holistic approach to injury treatment. This means embracing a biopsychosocial model of rehabilitation that addresses beliefs, enhances knowledge of pain-related biology, and reduces catastrophizing.

The Unfortunate Reality of the Healthcare System

While we know that this biopsychosocial approach represents the current best practice for managing most injuries, it is still not widely implemented in standard clinical practice. Real limitations within our healthcare system impact this, though that is not the primary focus of this discussion. The bottom line is that many patients struggle to find a provider who:

• Understands updated evidence about pain science and upper extremity RSI issues.
• Has the necessary time to conduct a thorough clinical exam and provide comprehensive education.

This often leads individuals like you to seek answers online, reading articles like this one. I want to assure you that such providers do exist. If you haven't found a good one yet, keep searching. Ultimately, you are the most important advocate for your own health and healthcare experience.

We hope this case study has offered you hope and valuable insights. Please share this article if you found it helpful.

Ready to Fix the Root Cause?

If you're struggling with chronic wrist pain or other gaming-related injuries and are ready to explore a comprehensive, evidence-based approach to recovery, we invite you to schedule a free 60-minute consultation with our expert team at 1HP. This is your opportunity to discuss your unique situation, understand the potential underlying causes of your pain, and learn how our specialized physical therapy can help you get back to gaming and living pain-free.

Apply for your free consultation today!

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