16 Nov GAMERS THUMB – RESOLVING PAIN FOR A CASUAL CONSOLE GAMER, PART 1

Welcome back to another case study! This one involves a casual console gamer I worked with to reduce his pain and develop better habits around health. He graciously agreed to allow me to publish this case study to help anyone who may be dealing with thumb pain learn how they can better approach it

BRIEF PICTURE OF THE PLAYER’S PAIN

Name: John X
Game Title: Smash, Xenoblade Chronicles
Level of Play: Casual
Age: 22
Console Details: Nintendo Switch, Pro Controller

What’s Happening: R. Thumb Pain in the region shown. Minor pain since 2015 which has gotten progressively worse. In 2017 had constant pain while gaming. Saw a CHT who requested an MRI (fortunately it was out of his price range). Referred to PT which helped temporarily although was not provided with a deep understanding of his Dx and how to resolve his pain

What is the player feeling? John reported one primary pain sensation at the muscle bulk of his thumb

P1: Sharp then aching pain at his thumb in the regions shown. The pain escalates depending on the length of the activity. Currently he reported the aching sensation at his thumb to be 7/10

Important Aggravating Factors:

1. When pressing the thumb toward the base of his pinky he would feel some stiffness and pain 7/10
2. Typing / Browsing his phone for 3-4 hours, reports 5/10 pain at the EOD
3. A slower game like Xenoblade Chronicles for 2 hours will cause his pain to escalate to 6/10
4. A faster game like Smash for 2 hours causes his pain to go up to an 8/10
5. Any combination of these activities typically increases his pain to 9/10

What he was looking for with Physical Therapy: His main goal with Physical therapy was to understand what was wrong and know what he could do to manage & recover from this issue. He was also concerned in learning what he needs to do to PREVENT the same issue from happening in his left thumb as he has begun to feel some slight sensations of aching on his Left. It was important he is able to continue to play video games casually. 

CHRONIC GAMERS THUMB FOR A CASUAL CONSOLE PLAYER

What’s Happening (medically) with this player? 
John is a 22 year old student dealing with chronic gamers thumb. It is a combination of a muscle/tendon issue with the muscle flexor pollicis brevis as the primary muscle involved in addition to the others within the thumb muscle group). His pain is primarily associated with OVERUSE due to poor endurance of the thumb muscles (FPB primarily). Although other contributing factors to his pain include his previous lifestyle (excessive use without awareness of how often he uses his thumb/hand, no regular exercise) and some adaptations in his nervous system (increased pain sensitivity).  

I have to also say medically he was mismanaged by previous MDs, CHTs and even Physical Therapists. This is a simple case and due to poor medical management he dealt with this much longer than necessary. All of these factors led to irritation of his thumb muscles/tendons leading to his inability to play for short periods of time without pain. An important part of this case was how long he had been dealing with the pain – which often leads to increases in sensitivity (more pain despite less activity) which does not accurately reflect the current state of our tissues. Part of my work with John was to help him understand this adaptation so there was context behind exercising despite pain being present. 

DAY 1 – EVALUATING GAMERS THUMB AND PLAN TO ADDRESS INJURY

EVALUATION AND PROVIDING THE PLAN
As with all physical therapy evaluations, I went through thorough questioning and clinical tests to rule out more serious involvement. I was able to confirm my suspicion of gamers thumb and increased nerve sensitivity through some clinical tests and inquiring about the history of the pain. Here are the results of the evaluation

Source of Pain: We identified the source of the pain to be the flexor pollicis brevis (P1)
Cause of Pain: As mentioned above the main causes of his pain are

1. Poor Endurance of Thumb / UE muscles
2. Previously Poor Lifestyle Management & Poor Medical Management
3. Increased Nerve Sensitivity

General Weakness and poor endurance of his thumb and hand/forearm muscles

John’s thumb endurance was significantly lower on the right side compared to the left. Individuals without pain should be able to complete 60 repetitions with minimal to no discomfort or issue. This is a large reason why John had difficulty with performing any thumb-related activity without pain or irritation and was a risk factor for him in developing more severe issues if not addressed. I helped John understand the framework of overheating in understanding gaming injuries and how his hand conditioning will be important for him to return to his prior level of function. 

With John’s schedule as a student (and fortunately it being in the summer) it was easier for us to implement some changes to his habits and initiate an exercise program he would have high compliance with. I helped John understand it would take likely 2 weeks to notice a change in symptoms and 4-6 weeks to make a change in his strength based on his current endurance. 

Lifestyle Habits & Increased Nerve Sensitivity (Central Sensitization) 

The other important aspect of treatment and management for John’s injury was to help him better understand the increased pain sensitivity he had been dealing with due to the chronic nature of his injury. As I mentioned earlier his pain at this point did not accurately reflect the state of the tissues. To be brief about this our bodies learn overtime how to deal with pain and protect an area. Though tissue has healed, there are increased nerve endings along with upregulation in the production of nerve signals at the injury site increasing pain signals being sent. Basically, the longer we have pain, the better our nervous and immune system learns how to make pain. You do not have any control over this (See Explain the Pain, Supercharged) . Fortunately we can retrain this system and movement is a part of it. Evidence provided in the book and the research articles associated show that movement helps normalize the pain sensitivity. 

Lastly it was important I helped him understand the importance of load management or being more aware of when he utilizes his thumbs/hands throughout the day and how it impacts his injury.  Fortunately, since he had been dealing with this for the past two years he had already begun to modify his schedule and develop some basic awareness with his pain. 

Rehab Program for Gamers Thumb

Specific Program as Follows (Keep in mind this worked for John based on the specific things I was able to identify during testing. This however can be a good general THUMB management program for those who have thumb pain in the same area. Always seek out a Physical Therapist to receive a diagnosis and individualized treatment program for yourself!)

Building better habits – Exercising & stretching regularly for Gamers Thumb

It was important that I worked with him to develop better habits around managing the health of his thumb and hands. A major focus for any individual dealing with pain is to better manage their schedule and lifestyle around their injury to create the right environment for recovery. This meant beginning an exercise routine to develop better tolerance to repetitive loads in addition to stretching more regularly after excessive use of his thumb and hand muscles. 

Exercise Routine for Gamers Thumb

With this in mind, I designed him a gaming-specific workout routine with the following strengthening & posture exercises. I used a combination of exercises from previous videos and some novel exercises I created. 

1. Theraputty Exercises
– Thumb Adduction: 3×10 1x/day
– Flat Finger Pinch: 3×10 1x/day
– Thumb Pinch: 2×10 1x/day
– Wrist Squeeze & Curl: 3×15 1x/day

2. Cup Isometric Hold 2×12 (5″ each)

Another basic strengthening exercise I provided John. The goal with each repetition was focus on utilizing the thumb to squeeze the cup. This helped with better activation of his thumb muscles.

3. Stretching: Thumb Stretch 3×20″ up to 5x/day, to be performed after any activity which utilized his thumb muscles excessively. I went over a few of these with him which included (phone use, lifting or gripping activities, etc.)

4. Bonus Routines
– 6 Minute Post Session Stretch Routine
– 9 Minute Wrist Warrior Routine
– 9 Minute Thumb Protection Routine

I helped him identify the right times to perform these exercises throughout the day in order to avoid fatiguing his muscles prior to play. As mentioned stretching primarily after any activity which required thumb activity (gaming, mobile use, gripping, etc.) as muscles tend to stiffen up after repeated use (over the course of a scrim block or lengthy gaming/computer session) so the best time to do these stretches is IMMEDIATELY AFTER THE SESSION! 

Improving his awareness of muscle Activity for Gamers Thumb

Another important discussion I wanted to have with John was developing better awareness for load of his thumb-use throughout the day. This meant describing and understanding all of the daily activities which utilized his “thenar eminence.” For him this meant activities like typing, lifting and carrying things which involved opposition, mobile use and more. 

By better understanding his load throughout the day he was able to make better decisions around the length of time he would play or participate in certain activities which would require excessive thumb use. The end-goal with this part of the education was to help him realize what he does throughout the day influences the stress on the tissue. With this understanding he could utilize exercises or modalities (ice, brace, self-massage) to directly address his tissue stress.

CLOSING UP: PATIENCE IS KEY FOR GAMING INJURIES

It is important to understand as a gamer what you need to do in order to return to 100% function. I made sure by the end of our initial visit John understood exactly what he needed to do over the course of the next few months (6-8 weeks) to recover fully. This is why I did not need to see him for about two weeks and scheduled our follow-up for that time. As a last note I emphasized for him due to his history (pain since 2015) he needs to have patience with the process because we are targeting changes in his nervous system (elevated sensitivity due to chronicity), habits and actual physical impairments. Tissues, Nervous system and habits take time to change – we all need to understand this

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This ends PART 1 of this case study – in the next part you find out how John does at the end of the 6 weeks and the IMPORTANT LESSONS YOU NEED TO KNOW if you are dealing with thumb pain as a console player. CHECK OUT PART 2 HERE