Should Uzi have retired? Thoughts from Esports Health Experts

Too Young to Retire – Uzi League of Legends

As of June 3rd, 2020 the legendary League of Legends ADCarry “Uzi” retired. In the statement given by Royal Never Give Up (RNG) it had mentioned injuries contributing to this decision: “Due to injuries accumulated over eight years of high intensity training, at the suggestion of medical professionals, Uzi was advised to rest during the 2020 LPL spring split. After spring a decision was made and we understood and respected his wishes, and will continue to assist him.” What sort of health conditions could have led to this decision and is there more that we could uncover from analyzing his interview video & Nike LPL documentary? In this article and reaction video the esports health experts with 1HP provide all of our thoughts associated with Uzi’s retirement along with look to answer some important questions
  1. Could he have continued to play / Should he have retired?
  2. What were some other factors which might have led to his retirement and his injuries health issues?
  3. What can we do next for Uzi injuries?

Credit to LoL Esports

1HP Staff thoughts about the Nike Documentary & Retirement Interview

The first thing we want to discuss is all of the information provided to us in the Nike LPL documentary provided in the link above. At this point we know Uzi has already been struggling with health issues starting in 2017 from which he had to take a break followed by another one in 2018 and 2019. There have been repeated exposures to this “rest” recommendation made by the medical professionals working with Uzi which even in the interviews make it very clear to us
  1. Uzi did not have a clear understanding of what he was dealing with (tendon vs. nerve vs. muscle)
  2. The medical professionals working with him prescribed rest and some form of physical therapy. Details are unknown but based on his discussion he had a terminalistic belief and understanding of his own health
With this in mind let’s review some of the key points of information provided in this video.
Credit to LoL Esports – 3:11

Professionals Practice 10+ Hours a Day

From my understanding and experience working in LCS this means they have daily triple blocks of scrims with the remaining time spent soloQing. With each scrim block being roughly two hours, that means 6 hours of scrims 4 hours of soloQ.

Pro Gaming Careers are shorter than most traditional athletes

This is true without a doubt. While they show some data there are quite a few factors to consider here that are outside of just health. With the sheer volume of players in China it can create a situation in which players are replaced constantly and are unable to return to one of the few professional spots provided in the LPL. The industry is also quite young in nature so there is not much understanding by medical practitioners working in the space GLOBALLY to address these SIMPLE orthopedic issues. It becomes a complex and difficult situation when pain and injury duration is extended through a phenomenon known as central sensitization but all of the context surrounding injury.
  • “Can I still play?”
  • “Will I still be able to play at my peak?”
  • “Do i have carpal tunnel syndrome?”
  • “Is my injury reversible or will I have to do exercises forever?”
  • “What am I dealing with and when can I return?”
If these questions are not answered properly it can lead to poor self-efficacy and ultimately affect not only the physical but mental health of the athlete. While there are likely other factors to discuss we will leave it at that. Additionally in this section (~3:55 in the video) the individual speaking mentions the difference of traditional vs. esports in its “impact.” This is also true and has been defined by us quite awhile ago regarding how we could characterize esports as.. “A static endurance sport challenging our executive functions in a virtual environment” While it is no doubt shocking about the length of the careers it is NOT a surprise. Not at all. With the current level of infrastructure of player care, understanding of the general medical professional with treatment along with the youth of the industry there is NO surprise careers are this short AND why there are injuries which end up in retirement.
Credit to LoL Esports – 4:41

Uzi Orthopedic Concerns & Nike’s Movement Evaluation

At 4:41 in the video Uzi describes some of his pain in his shoulder stating it potentially affects the rest of the arm making it feel “retired” already. Based on his reported symptoms I would suspect two potential issues drawing from my experience with pain patterns I’ve seen over the past few years
  1. Mid-Back Spine Irritation (Sliding joints at his mid-back) due to his rounded posture
  2. Nerve Irritation at his shoulder/neck (Thoracic outlet syndrome) leading to the potential radiating pain.
The things I would be looking to rule out are neck (at his spine) related pain which are typically uncommon for gamers and in his age group. There are also likely consequential impairments of the nerve irritation leading to more risk of pain or injury at his wrist/hand. Ultimately however it requires specific management to identify the physical contributing factors leading to tissue stress he is experiencing. In the video the experts working with Nike perform an evaluation of the LPL athletes general movement capacity (through a movement assessment framework known as Selective Functional Movement Screen) and their executive function through some unique tests. There may have been more specific assessments performed by the Nike staff which was not shown in the video. I am happy Nike took the approach to perform a full movement assessment of the athletes as it can clarify general impairments which can contribute to the orthopedic issues we often see in gaming. It seems Nike also was able to follow-up with a few of the teams to perform some education and training on some of the impairments found which is also extremely helpful for the players. The only concern I have is how any active injuries or specific concerns noted by the athletes were addressed and if there were any “esports-specific” assessments complementing the SFMA or movement screening. When I entered the esports space I also drew from the components of the SFMA & movement science principles to design an assessment specific to gaming and added a few additional tests I feel are extremely relevant for gamers or those sitting for an extended period of time utilizing their shoulder / forearms (endurance tests of commonly used muscles to establish normative values).
SFMA Examination – Credit to LoL Esports
My work with teams is approached in a similar fashion with added individualized care for the specific injuries and pain patterns the players might have. In this case it would be extremely important for me to address some of the beliefs arising from the individual interviews and how they perceive their own physical capacity going forward. I believe the Nike specialists established a great foundation for general injury prevention in the LPL and are completely accurate in understanding the gaming population is less conditioned than that of the general population. I feel the next step is creating a system to better address individual orthopedic needs which I feel is largely due to the lack of understanding of medical professionals in treating tendon-related injuries (there is of nuance associated with belief management + increased nerve sensitivity). Some highlights of what I was able to pick up from the Nike “Evaluation” & “Reboot” section of video are
  1. Great approach for their training plan-
    1. Increasing core-control and intra-abdominal pressure (IAP) through breathing exercises
    2. Postural endurance and scapular stability exercises
  2. Love that they had an interview to understand lifestyle of the athlete to likely make more guided recommendations
  3. Uzi has extremely poor upper body & core stability as noted through his inability to lift his arms up in the quadruped position.
A really important question from here – AFTER the assessment is..

What is done for the players and athletes?

Are there player health standards established they have to meet in order to play or participate in the LPL? (Riot if you are reading this I have these normative values and have been using them in the past 5 years for all the teams I work with :D). Ideally the teams are given a report of their athletes and are required to have staff hired to address the specific concerns they might have (general impairments and individualized orthopedic issues). How close are we to this? A few years out – I still feel there is a large gap in understanding of medical professionals in how they treat and work with gamers (majority of recommendations from older MDs are to rest and perform passive treatments). 1HP is hoping to help close this gap. These are all important points and thoughts to make as we enter the second part of this article – the review and discussion of Uzi himself.

UZI’s Retirement Interview

Now of course let’s get to his actual interview. Caitlin and I have a live reaction and discussion in the video below but I do want to discuss some key points & thoughts from this video.
 His health is the largest reason why he decided to retire
It is evident he has large concerns about how his lifestyle as a pro has contributed to the issues he is dealing with. The two overt issues we can identify through his interview are
  1. Orthopedic Concerns (R. Shoulder Pain, Weakness of the R. Arm/Hand)
  2. Type II Diabetes – requiring daily medication (metformin)
The good news about these issues is that they are REVERSIBLE with proper health management and lifestyle modifications. That’s right both his shoulder / arm issues AND the type II diabetes are reversible. This is an important fact Uzi hopefully has been educated on by the medical professionals handling his care. I am unfortunately not optimistic that he has been informed of this given how he speaks about his condition.

“Can I really carry on practicing more than ten hours a day? What I worry about the most is that, if I can’t keep up with this intensity, I might not be able to maintain peak form. If i really return to play with these kinds of health factors I might not be the ‘best me’ in everyone’s eyes”

Let us unpack the belief underlying this quote. BELIEF: Practicing 10+ Hours is the only way for him to improve, maintain his form and achieve his high level of play. Ah the good old misconception of performance and skill development. While this belief has no doubt been gradually changing over the past couple of years – during the course of Uzi’s career the culture around improvement in gaming revolved around this idea. “I need to just play more to get better” China and Korean esports have been notorious for this in the past and it definitely adds more complexity to the issue if any management or performance specialist comes into the team environment asking the team to “work smart vs. work hard”. Working smart might mean leveraging some of those 10 hours for out-of-game optimization (sleep, nutrition, exercise) which will increase the quality of the actual hours used for practice. It might mean VOD review sessions to better understand concepts and further understanding of meta at different points in the season. There are endless ways gamers might be able to use their practice hours to move their OVERALL player development forward. This is where a lot of technology comes in and is the basis for Nike seeking to better understand the cognitive / executive function metrics underlying esports performance. Performance and practice cultural beliefs in Chinese / Korean professional play While it is easy to mention all of these different mediums for player development – it is extremely difficult to change behavior and culture already established. It is even more difficult when an individual who might be open to the idea has the external pressure of his/her peers taking the “culturally-accepted” path of improvement. This will prevent Uzi or any other player in the Asia / Korea region from wanting to commit to “playing less.” So Uzi unconsciously adopts this framework playing at this state of esports development. He firmly believes he has to play 10+ hours to improve, 10+ hours to maintain form and achieve his high level of play. And it is a double-edged sword when he is met with all of his success as it seemingly creates support for this type of behavior. AND as we can see in the quote himself – he will have this constant worry or pressure of “everyone” seeing him not being at his potential best. But if we zoom out we realize that everyone in the Asia community is “grinding” with this framework in mind without knowing the other path which Uzi is now forced to adopt can achieve likely the same results if not more. How do we know this? Evidence with ANYTHING competitive or traditional sports. We are still in the early stages of esports – but just as basketball players have gradually increased their size, power, speed and knowledge of the game over the history of basketball esports will do the same. We will eventually adopt the appropriate and balanced performance framework allowing gamers to reach newer heights in performance. So with all this being said – we know with a high degree of certainty Uzi does not need to practice 10+ hours for him to improve, maintain his form and achieve a high level of play. BUT we can also say it is possible for him to play a high training volume  (8-10 hrs a day) while maintaining peak health. It is all about how we prescribe and modify the changes to his life outside of gaming. And this leads us to another quote of his in the interview.

“It feels like I didn’t do better in the things that I could’ve done better in. I really feel like, if there was still enough time, I could still do it”

Belief: I do not have enough time to fix what I am dealing with currently – It will take a long time to make the changes to allow me to play 10+ hours a day and feel at my peak.  Uzi has the underlying belief he does not have time while he is 23 to address his health concerns and reach the point where he can play at his peak. As an esports medicine expert treating a wide variety of acute to chronic injuries in the past 5 years (with one player similarly dealing with pain for 6+ years now able to play with full volume without issues) I am confident his orthopedic issues can be properly addressed in the course of a year. While it may not take this long for the actual necessary tissue adaptations I consider a year to provide him with movement confidence and giving him referential experience to increase his self-efficacy. And while I cannot speak directly to the timeline regarding his Type II diabetes it has been shown with a specific (low calorie) diet protocol and proper lifestyle changes individuals were able to reverse their symptoms in 3-6 months. Of course there are quite a few variables to consider but it requires medical professionals to be up-to-date with the research to effectively and efficiently guide Uzi towards partial or complete remission. Uzi is ONLY 23 – there is no reason he should have this thought and it is encouraging that at the end of his interview he does leave some room for potentially returning if he is able to properly recover. There is no doubt he feels this is too early and hopefully with the right medical team around him he is able to make this a reality.

Answering some final questions –

Now that we have offered our overall thoughts on both the Nike Documentary & Uzi interview – I hope we have been able to answer some of the questions posited above. Here is our team’s response to the questions:

1. Could he have continued to play? Should he have retired?

Matt: If we look at his case objectively without considering external pressures and necessary systemic changes I firmly believe Uzi could continue to play despite his orthopedic and medical concerns. It would require clear education of his condition & recovery. Medical staff would have to coordinate extensively with coaching & team management to ensure his workload & training is properly managed. This means being able to make non-negotiable limits to his play and practice time and having Uzi / RNG buy into this evidence-based framework. It will likely mean he would take a full split or year off from professional gaming to work completely on his rehabilitation. This would not mean he is unable to play but has a better understanding of how to self-manage his own condition to ensure he can play without health impairment.
???? – Credit to iCrystalization & 央视网

2. What were some other factors which might have led to his retirement and his health issues?

Matt: I believe I answered a lot of this above but will briefly recap here
  • Education around his orthopedic issue and health concerns
  • Culture of practice and Uzi’s performance framework
  • Poor lifestyle management and conditioning leading to the issue in the first place
  • Lack of team & league infrastructure to support this
Elliot: Any doctor that tells you your anything is X years old has no reference for that statement. Bodies age as well as they are taken care of. 80 year olds can be bodybuilders just as much as they can be frail. It’s always important to get advice from medical professionals that understand the relevant anatomy and how movement can have positive and negative effects on the structures. Any doctor who’s primary method of treating dysfunction is surgery or pills should be regarded cautiously. Doctors of Physical Therapy are movement experts and can help you understand your body problems in a way that is relevant to the activities you do on a daily basis. It’s also very important to find a therapist that understands the demands of esports and all that it entails from the mental to the physical. Doesn’t seem like the underlying pathology was addressed. Seems like from the videos that treatment was being performed in forward head rounded shoulder positions that did nothing to address his likely thoracic outlet syndrome.
  • Frequent absences during the splits indicate that the problem was not being managed from a graded exposure standpoint. The issues should have been able to be dealt with while maintaining participation in esports win increased restrictions on time played and hourly breaks required.
  • His statement that he had to recently begin taking medication for his diabetes most likely indicates that it is lifestyle (reversible) diabetes. Working with a health coach for nutritional consideration likely could have reduced the effect of this comorbidity and helped accelerate recovering from his musculoskeletal conditions.

3. What can we do next?

Matt: While I think Nike’s program is an amazing step towards optimizing health of esports athletes in the LPL. I believe they are missing the added component of establishing injury standards (for which they do not need to have an excessive amount of data to determine). There are existing tests and examinations for the muscle groups & impairments we might expect in a gaming population and I have already implemented this in the 3 teams I have worked with in the past (CLG, IMT and now LA Gladiators). This does however mean there needs to be more healthcare professionals educated on how to properly manage the gaming population. Growth in both of these areas need to occur for “early retirements” to be a thing of the past in esports. So ultimately what we need are
  • League Player Health Standards, Minimums to participate. MEDICAL CLEARANCE TO PLAY (Hi Nike/Riot, we can help with this. We have an esports specific screening with 5 years of data across multiple esports)
  • Advanced education for healthcare professionals globally (don’t worry everyone 1HP is working to achieve this and we will lead the charge in this).

And.. that is all. Hope anyone getting to this point was able to learn a little more about where we are in the current state of player care & management in professional esports.

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