20 Jan HAND PAIN WITH GAMING? YOU MIGHT BE DEALING WITH THIS!
Pain Pattern: Frozen Fingers/Fox Fingers
One of the most common pain patterns I see as a physical therapist in esports is this: sharp or achy pain and stiffness across the back of the hand, usually along the lines of the fingers, sometimes extending into the forearm with tightness, fatigue, and cramping.
I see this most commonly in two fairly similar contexts: in Melee players who main Fox, and in PC gamers who play high APM games/characters (think Invoker in Dota 2, or rhythm games like Osu!). The common denominator is faster inputs, which means more inputs over time.
Don’t worry–pain like this doesn’t mean you have to take up playing Puff or give up Starcraft. In this article, I’ll break down what this pain pattern is, how it happens, and what you can do to prevent and manage it.
The What: Extensor Indicis and Extensor Digitorum Tendinopathy
This pain pattern falls into the category of “tendinopathy”, or an injury/irritation to a tendon.
“Tendon injuries are often called “tendonitis”, which isn’t accurate. “Itis” refers to inflammation, and many of these injuries/pain patterns aren’t caused by inflammation of the tendon. “Tendinopathy” is a broader category that accounts for different causes of tendon injury.”
Tendinopathy is usually a better descriptor for your gaming pain– Dr. Caitlin McGee
Your extensor indicis and digitorum muscles are responsible for extending (raising) your fingers. Because they cross your wrist to reach your fingers, they also assist in extending your wrist. These muscles originate further up the forearm, near the elbow. The muscles are entirely contained in the forearm, while the tendons enter the hand and fingers to carry out muscle action.
There are four main types of impairments associated with this particular injury: mobility, power/endurance, and coordination, pain system. All of these impairments tie into each other and rarely exist in isolation.
Limited mobility of the wrist into extension creates increased passive resistance for the wrist extensors, which leads to faster fatigue and strain/pain onset. Decreased endurance and power of the extensor indicis and digitorum results in compensations from other muscles in the forearm that put additional strain on the wrist and elbow. Coordination issues, like being unable to perform finger extension without also performing wrist extension, increase strain on the extensor indicis and digitorum by requiring sustained contraction.
The How: Repetitive Stress Injury
This kind of tendinopathy is usually a repetitive stress injury, rather than an acute injury like tripping and spraining your ankle. An acute incident like lifting something too heavy or being in a car accident can be the thing that tips a low-level strain or irritation into persistent pain, but an injury like this doesn’t happen overnight. It builds up over time when tissues that aren’t adequately trained in strength, endurance, or coordination are placed under strain that they’re unable to adapt to.
That doesn’t just mean your muscles are weak or lacking in stamina. It means the specific conditions you’re placing your muscles under are too much for them. Those conditions include strength and endurance, generally, but also things like:
- Mouse size and grip type
- Controller grip tightness
- Practice frequency/rest frequency
- Tournament schedule and periodization of training
- Wrist position
- Forearm support
- Overall posture
The Fix: Load Management
The fix for this issue falls into two categories: prevention and management.
Prevention
Prevention includes any action we can take to avoid this issue in the first place. The first and easiest prevention strategy to implement is conditioning. Conditioning involves using stretches and exercises to improve your strength, coordination, and endurance. This first series of exercises is ideal for performing either before practicing or during rest breaks while practicing.
This guide (skip to 1:27 if you just want the walkthrough) is great for a morning routine or daily wrist injury prevention. Here is another walkthrough that can be helpful (9 minutes long!)
If you want to build your own routine, make sure to include three components: wrist flexion stretches (like exercise #4 in the infographic) to improve feelings of stiffness in the wrist extensors, wrist and finger extension mobilization to improve range of motion, and endurance exercises that involve finger extension without wrist extension (that is, keep the wrist the still; focus on moving the fingers).
Prevention isn’t just about exercise, although exercise certainly helps. Ergonomics, posture, and scheduling are also elements of preventive care.
POSTURE & ERGONOMICS
When it comes to ergonomics and posture, the most directly-relevant factors are your wrist position and your arm support. Your wrists should be in slight extension (<15 degrees) and neutral ulnar/radial deviation, which looks like this:
 |  |  |
Your forearms should be supported either on your lap or on armrests; whichever allows you to remain sitting upright and relaxed. Your forearms should not support your bodyweight, as slouching or leaning forward onto your elbows puts a significantly larger load on your forearm muscles and causes them to fatigue sooner.
SCHEDULING FOR FROZEN FINGERS/FOX FINGERS
Scheduling should address both long-term and single-practice load management. In the long term, your schedule should be sustainable and periodized. Periodizing refers to the ebb and flow of intensity and duration of practice throughout the season. For example, while you might bootcamp or increase intensity about 2 weeks before a tournament, you’d taper down your training in the days immediately leading up to the tournament. You should build in rest breaks and downtime that allow you to recover after tournaments and prolonged periods of practice/competition.
Scheduling should address both long-term and single-practice load management. In the long term, your schedule should be sustainable and periodized. Periodizing refers to the ebb and flow of intensity and duration of practice throughout the season. For example, while you might bootcamp or increase intensity about 2 weeks before a tournament, you’d taper down your training in the days immediately leading up to the tournament. You should build in rest breaks and downtime that allow you to recover after tournaments and prolonged periods of practice/competition.
Your schedule day-to-day should also have rest breaks built in. You should be getting up to move around and change positions every 45-90 minutes. Use your rest breaks to stretch, mobilize, walk, hydrate, eat–anything that isn’t strain on your hands and fingers.
Management for Frozen Fingers/Fox Fingers
If you’re already dealing with pain, the preventive techniques explained above are still relevant. However, you’re also going to want to get your pain, irritation, and fatigue under control. The techniques that will work best will depend on your impairments.
Modalities like ice, heat, and kinesiotape are short-term pain management techniques. They will not fix your injury in the long term. However, they may improve your pain to a degree that allows you to do the stretches and exercises that will address the underlying endurance, mobility, strength, and coordination deficits that cause the pain in the first place.
Self-massage is useful to increase bloodflow, relax muscles, and provide a deep pressure sensory input. That input is important in chronic injuries, as nerve receptors become more sensitive to nociceptive or noxious/painful stimuli over time. Providing a drastically different sensory input helps to change that sensitivity. Cross-friction massage can also be used in short bouts (1-2 minutes) to provide mild irritation to the tendons and kickstart the inflammatory cycle.
Inflammation is actually useful–sometimes. When you’re initially injured, inflammatory factors come in to clear out damaged tissue. Research supports the use of cross-friction massage for chronic tendon injuries.
Dr. Caitlin Mcgee
EXERCISES FOR FROZEN FINGERS/FOX FINGERS
Exercise is also key to recovery. When it comes to tendon injuries, moving through the full range of motion against resistance is often too painful at first. Isometric exercises, or exercises where you resist a joint being moved, are often a good place to start. Isometrics should be held for 10-15 seconds, 10-20 times.
 Finger Extension Isometrics |  Wrist Extension Isometrics |
1HP RX: 10x, 10-15″ Holds Each
After isometrics, the next progression is to eccentric exercises. Eccentric exercises are ones in which the muscle is being lengthened while contracting–think the “lowering” portion of a bicep curl, or the downward portion of a squat. The motion should be slow and controlled. I recommend using a metronome to maintain consistent timing as you raise and lower with resistance. Start with 4-5 sets of 10-15, progressing to sets of 30.
1HP RX: 4×10 -> progress to 4×30
Stretching is also part of a well-rounded management program. In addition to wrist flexion stretches, you can focus on individual fingers that are particularly irritated. If limited wrist extension is contributing to your pain, it’s also important to stretch the wrist flexors and mobilize the wrist joints. You should hold each stretch for 30-60 seconds; you should pulse the mobilization 40-50 times slowly.
 L. Index/Middle/Ring Bias |  R. Index/Middle Finger Bias |
1HP RX: 2-3×30″, 40-50x oscillations
Last but not least, you can mobilize the tendons that are directly involved. Complete 10-15 rounds, holding each position for 3-5 seconds.
The Wrap Up
If you’ve got pain in the back of your hand and into your forearm, it might be coming from extensor indicis and extensor digitorum tendinopathy. This is a repetitive stress injury that comes from inadequate strength, coordination, mobility, and endurance, and is exacerbated by poor posture and ergonomics. You can prevent it with improved ergonomics and simple exercises, and you can recover from it with a combination of modalities that provide short-term pain relief, soft tissue mobilization, stretching, endurance exercises, and easy modifications to your schedule and setup.
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