Carpal Tunnel Syndrome
Carpal Tunnel Syndrome (CTS) is a condition that affects the median nerve in your wrist. The carpal tunnel is a narrow passageway in the wrist through which this nerve and several tendons travel from your forearm to your hand. The median nerve controls sensation and movement in the thumb and first three fingers of your hand.
“An analogy that can be used to think of nerves is like a water hose. When a water hose has a kink in the line there may be a little water sputtering out which can be like the tingling often first experienced with some prolonged bending at the wrist. With a large bend in the line this results in no water coming out, similar to when an individual sleeps with their wrist extremely bent and wakes up with a numb hand. Similarly this can also occur with pressure being placed on the nerve or hose. If someone comes along and steps on the hose then water may stop or sputter out just as if external pressure from a keyboard pad is being used. If there is no water coming from the hose to feed the plants then the plants will begin to die after months, similar to how our muscles can start to atrophy (die/weaken) if they are not getting proper innervation (supply) from the nerve.”
Repetitive hand and wrist movements, especially those involving bending and flexing the wrist, can lead to irritation and inflammation within the carpal tunnel. This can compress the median nerve, resulting in symptoms like numbness, tingling, and pain in the thumb, index finger, middle finger, and half of the ring finger. Now this means it is no surprise where it can be brought up heavily with gamers or office workers because a lot of what these require is repetition, but this seems to be much less frequent then believed. There are several reasons for this, but ultimately age is a major indicator where thickening of the transverse carpal ligament has likely not developed. Instead, tendinopathies are much more commonly seen in gamers and when pain is reported at the wrist, this should first be considered.
Typing, using a computer mouse, and performing tasks that involve gripping or vibrating tools for extended periods are common activities that can contribute to the development of carpal tunnel syndrome. Additionally, certain factors such as genetics, obesity, pregnancy, age, gender, and underlying health conditions can increase the risk of developing this condition.
The name “Carpal Tunnel Syndrome” is derived from the anatomical structure involved, where the median nerve passes through the carpal tunnel in the wrist.
Gamers are likely to begin experiencing tingling or numbness in the *median nerve distribution. Gamers may report feeling “slow” or weakness gripping the mouse. Finger dexterity is likely to be reduced which is likely to decrease performance and alter the gameplay of the individual. Individuals may also experience a burning sensation, but when pain is reported without numbness/tingling suspicion should then be placed on a tendon injury. Again, tendon injuries or tendinopathies are much more common in gaming and it is important to understand this as treatment differs.
Data suggest tendinopathies as being a far more prevalent condition than CTS (Hwu, 2021). When it occurs, CTS is brought on by a variety of factors, including a lack of rest breaks (Feng et al., 2021), overweight/obesity (Shiri et al., 2015), wrist angle, repetitive gripping, increased swelling of the hand/wrist, sleep positioning, anthropometric measures, use of vibrating tools, and cold temperature. Women are often known to be 3x more prone to developing CTS, but when strictly looking at the occupation of data entry there was no significant change which for gamers may be the most practical comparison (McDiarmid et al., 2000). Gamers in particular should be aware of maintaining a neutral wrist or small wrist extension angle when using a mouse, setting rest breaks every 30 min, and monitoring their sleeping position so as to not have wrists excessively bent.
*Median Nerve: Supplies the thumb, index finger, middle finger, and the radial half of the ring finger on the palm (volar) side as well as the back (dorsal) side of the same fingers discussed, but only past the first joint in the fingers (distal to the proximal interphalangeal joint).
The following information is provided for general educational purposes only and should not be considered medical advice. It is not intended to replace consultation with a qualified healthcare professional. If you have specific concerns or questions about your health or medical condition, please seek the guidance of a licensed physician or another qualified medical practitioner. Any reliance you place on the information provided is solely at your own risk. In no event will the author or 1HP be liable for any loss or damage arising from using this information. Always consult with a healthcare professional before starting or changing any medical treatment or regimen.
Perform this quick test* shown here to screen for this diagnosis. If there is numbness/tingling (paresthesia) experienced in the area highlighted then this may indicate a you have this condition.
Instructions: Position the wrists in maximal flexion and hold for 60 seconds
Gamers use their hands and fingers a lot! Gamers are at risk for injury because of the long durations we play, but this does not always indicate carpal tunnel syndrome. Instead, pain is more often reported which tends to be a result of tendinopathies, NOT carpal tunnel syndrome which will present as numbness/tingling. Gamers oftentimes take minimal rest breaks because they are so engaged and locked in and don’t always think to put their body first. Pain and discomfort is something that can be reduced from distractions and gaming is a good distractor which makes it hard for gamers to know when to stop due to pain/discomfort. Gamers are at risk however because of the positions they find themselves in when playing and the excessive use required of the hands/fingers. PC gamers in particular are at an increased risk compared to mobile and console gamers because the angle the wrist is positioned in. The position of the wrist is important as too much bending in either direction (Flexion/extension) can result in increased pressure of the median nerve. Instead, the wrist should be positioned in neutral without an excessive angle up which can occur if the mouse/keyboard sits too low or you yourself are standing or sitting too high. This is why ergonomics/positioning can be extremely important for some. It is important however to recognize these symptoms early on and when they occur. For example, CTS symptoms may occur at night while sleeping for those who sleep with wrists bent which is a very common time irritation can occur as your body is unconsciously positioning the wrist poorly.
Returning from this injury takes a concerted effort, but can be done without much time away from the game. Below are a few steps that individuals need to understand and take when discomfort in this area occurs.
Diagnosis specific tip: Utilizing a wrist pad may actually exacerbate carpal tunnel symptoms versus helping. Yes, there is benefit in having the wrist be in a neutral position, but there will now be pressure put on the median nerve from the resting position
*Surgery is rarely required in order to effectively treat, but can be extremely effective if indicated
The diagnosis was explained in short above, but for those wanting to know and learn more this is for you.
Specifically, this diagnosis is looking at one nerve, the median nerve and the surrounding tendons and ligaments. The median nerve is a mixed (sensory and motor) nerve which runs down from the brachial plexus. As it travels down the arm it continues between the flexor carpi radialis muscle tendon and palmaris longus tendon and then travels through the carpal tunnel. Once at the carpal tunnel, the median nerve along with 9 tendons run through this to the final destination in the hand. The carpal tunnel is formed by the carpal bones and the transverse carpal ligament (Flexor retinaculum) which acts as the roof as it is a connective band that stretches between the carpal bones therefore creating space for the tendons and median nerve to pass through. The human anatomy of the wrist is already a crowded one. When we start to include increased fluid retention, thickening of the transverse carpal ligament, hormonal changes, tendon inflammation, previous injuries, external compressors, or even anatomical variation then problems can develop. With any of these factors, there will be decreased space within the carpal tunnel resulting in compression of the median nerve. As the nerve gets compressed, symptoms will present in the region shown below.
Other involved structures:
It should also be known that gaming is not the only activity to bring on this condition and certainly other lifestyle factors play a role. School, work, hobbies, and sleep positioning can also further irritate this nerve and can be important to thoroughly evaluate as well.
Anterior interosseous nerve syndrome is a condition which results in pain on the anterior side of the proximal forearm. This is a compression of the motor nerve which would result in weakness for pinching and gripping of a mouse or controller and reducing overall dexterity and performance. This is unlikely to be a common gaming injury, but is still worth considering when discussing median nerve issues.
Pronator teres syndrome is a median nerve compression occurring near the elbow that often gets overlooked or even misdiagnosed as CTS. The pronator teres muscle is located within the anterior forearm where it originates at the medial epicondyle and coronoid process of the ulna and inserts on the radius. This muscle pronates the forearm, rotating the palm downwards. Similar to CTS, pronator teres syndrome may come on from repetitive grasping, but it is common with repetitive pronation movements as well.
Thoracic Outlet Syndrome (TOS) is another condition which should be assessed as the nerves discussed above all stem from something called the brachial plexus. The brachial plexus is a network of nerves that come off of the spinal cord and travel between the clavicle and the first rib down into the arm. The presentation can lead to confusion when interpreting pain or sensory disturbances throughout the arm, wrist, hand, fingers while it may be a result of entrapment further up the chain near the neck as opposed to the median nerve.
There are several approaches to take in order to prevent injury from occurring. There are 3 main factors to first focus on and address, but it is also important to keep in mind other secondary factors which can be helpful to address.
excess body mass on the risk of carpal tunnel syndrome: a meta-analysis of 58 studies. Obesity reviews : an official journal of the International Association for the Study of Obesity, 16(12), 1094–1104.
Written By: Brett Becker, OTR/L, MS, ACE-CPT