Inner Elbow Pain From Gaming

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Inner Elbow Pain From Gaming

Medial Epicondylosis | Golfers Elbow | Fighting Game Forearm

Expert Opinion

One of the most commonly injured areas in gaming due to the stress and strain put on the wrist/finger flexors
Fighting Game Forearm is irritation of just one or multiple tendons that cross the wrist and leads to the hand and fingers
These muscles/tendons are responsible for gripping a mouse/controller, when a button is pressed or action is completed. Whether that is clicking the mouse/keyboard, using your finger to hit a controller trigger, gripping a joystick, or tapping something on the mobile device.

Fighting Game Forearm is a condition that affects one or multiple tendons stemming from five muscles in your forearm, wrist, and fingers. Tendons are like little ropes that connect your muscles to your bones, and they help you move specific joints. When you play video games or use your wrist and fingers a lot, these tendons can get irritated and swollen, causing pain. These tendons in particular are what allows each person to bend their wrist/fingers and rotate their forearm palm down.

This diagnosis is termed “Fighter Game Forearm” due to the frequent occurrence in gamers who play fighting based games such as Mortal Kombat, Tekken, Street Fighter, etc with a joystick. This can also be present in PC or console gamers as a lot of the irritation can come from strong or forceful gripping of the device. In many games players are required to perform frequent actions for prolonged periods of time under high stress which can lead a player to excessively grip the device. Through improper positioning, poor conditioning, or inadequate rest these tendons will take the brunt of this and elicit pain. This name “Fighting Game Forearm” is also interchangeable with “Golfers Elbow” or medial epicondylosis.

Common Things You Might Feel?

Gamers are likely to begin experiencing pain and discomfort while playing and a sore, achey, or stiff feeling after in the area indicated above. Weakness is also likely to be present with gripping a controller, mouse, or using a gaming joystick for games such as Street Fighter or Tekken. This is likely to decrease performance and alter the gameplay of the individual where movements may be slowed or less precise. Pain may be present with activities such as bowling, golfing, rock climbing, or even just holding the phone to text.

Disclaimer

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.

How Does It Happen to Gamers?

Gamers use their fingers and hands a lot! Gamers are at risk because of the long durations we play. Oftentimes this means we are taking less rest breaks when we are in the zone because we don’t always think to put our body first. Pain 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. Gamers are also at risk because of the specific motions required when playing. Gamers playing high APM games under high stress are at an increased risk because of the repetitive strain in gripping the device. Each time we are hitting triggers or clicking a button, these muscles/tendons are being used. When proper care is not taken through adequate conditioning, rest, stretching, etc then the muscles/tendons will fatigue and lead to structural damage in the form of small microtears near the inner elbow.

For a short video explanation about how overuse injuries can develop in gamers and how to help them, check out the video linked here:

How to fix it / Recover / What can you do? Strategies to manage symptoms?

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 pain in this area occurs.

Identify the issue (One of the most important factors is early detection…do NOT push into or through pain)
Stress Management (Individuals with more stress who are unable to manage this may become more tense, therefore holding/gripping the input device much harder than what is actually needed leading to added strain)
Rest the wrist/fingers (Few days of reducing the workload, but be sure to continue moving the wrist, fingers, elbow)
- Splinting: This may be one way for individuals to rest the irritated tendon. It is important for a gamer to know that this should be used as minimally as possible, but may be necessary for very painful acute symptom management.
- A splint used for this diagnosis should be a standard wrist splint with the thumb free. This will restrict the irritated muscles/tendons from being used and allow the pain to subside while they heal.
- A counterforce strap can also be beneficial to compress the region of the irritated tendons, functionally creating a new muscle origin for the wrist extensors. This means that the tendons closer to the medial epicondyle are now able to have some rest and relief even when the muscles are being used. The pad should be placed on the outer part of the elbow 1-2 cm down from the medial epicondyle.
Massage in times of pain/discomfort
Utilize heat/ice (Hot/cold packs, warm water soak)
- Heat can be helpful before or during activity. Ice can be helpful following activity in the presence of pain. Be cautious using ice over specific nerves as this may lead to irritation.
Initiate isometric exercises **
- A good starting exercise to regain/maintain strength while limiting further pain or irritation
Stretching **
- Helpful in reducing pain throughout the entire range of motion
Isotonic strengthening **
- Necessary to improve strength and endurance to decrease pain while playing and prevent future injury from returning

Additional tip: Consider utilizing lifting hooks to help decrease the muscle recruitment necessary for pulling or certain gripping movements while lifting such as deadlifts, rows, bicep curls, lat pulldowns, etc. (Not an endorsement of IronBull Strength)

*Surgery is very rarely required in order to effectively treat

For a comprehensive guide on the exercises discussed, check out the videos on our Fix Elbow Pain link here**

Science Behind The Injury

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 five muscles and tendons (connect muscle to bone) which are responsible for bending (flexion) the fingers and wrist while also turning the palm down (pronation). These tendons known as the flexor-pronator group converge and attach at one common point known as the medial epicondyle of the humerus. Through repetitive use, inadequate amounts of rest, or forceful clicking/gripping the tendons can experience inflammation which if ignored may lead to structural damage over time. This overuse leads to a pain response to warn the body of damage so that individuals will stop the aggravating activity.

Tendons responsible:

Pronator teres: This muscle is responsible for turning the palm down (pronation) causing rotation of the forearm.
Flexor carpi radialis: This muscle is responsible for bending the wrist towards the palm (wrist flexion) and bending the wrist towards your thumb (radial deviation)
Flexor carpi ulnaris: This muscle is responsible for bending the wrist towards the palm (wrist flexion) and bending the wrist towards your small finger (ulnar deviation).
Palmaris longus: Not everyone will have this muscle this muscle (~15% do not), but if present, it assists in bending (flexion) the wrist
Flexor digitorum superficialis: This muscle is responsible for bending the fingers (finger flexion), but does not include bending the tips of the fingers.

*Most commonly irritated

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, and other hobbies can also further stress this tendon and can be important to thoroughly evaluate as well. This injury specifically can also be common in golfers (hence “golfers elbow”), climbers, servers, and other professions or hobbies which require consistent and sustained use of these muscles requiring forceful gripping and carrying heavy objects in a palm up (supinated) position.

Differential Diagnosis:

Cubital Tunnel Syndrome-Cubital tunnel Syndrome is compression or irritation of the ulnar nerve at the inside (medial) part of the elbow also known as the “Cubital Tunnel”. This is similar to carpal tunnel syndrome in a sense where numbness and tingling may become present in the hand, but differs in where someone will feel it. With cubital tunnel one would specifically experience altered sensation in the small finger and half of the ring finger closest to the small finger. This occurs often through excessive or prolonged bending (flexion) of the elbow as well as resting or leaning on the elbow over the cubital tunnel. When individuals hit their “funny bone”, this is them actually hitting the ulnar nerve as it travels through the cubital tunnel. This pain may run down through the forearm into the hands and fingers where it can be mistaken or confused with Fighting game Forearm.

Preventative Approach

There are several approaches to take in order to prevent this injury from occurring or coming back. 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.

Strengthening exercises (Important for building up a foundational base to allow the tendon/muscle to keep up with the workload they are being asked of)
Intermittent stretching (During and after gaming sessions)
Proper warm-up (Promotes blood flow to the muscles/tendons and lubricates stiff joints)

Additional

Ergonomics/positioning
- (Poor positioning could put the muscles/tendons in a compromised position which forces it to work harder therefore making it more susceptible to injury)
Rest breaks
- (Pain levels can be reduced through distractions. Gaming is a big distractor, meaning that individuals should take breaks every 45-60 minutes to assess how you are feeling. Additionally, the break may not need to be the same for each person. If the injury severity is high then it may be better to take more frequent or longer breaks vs someone who has mild stiffness or discomfort where breaks can be more infrequent or shorter in duration)
- Creating a schedule that works for you and your game is also recommended. For example, consider taking a 10 minute break after 2 ranked games (~60 minutes) or a short 5 minute break to stretch following 1 ranked game (~30 min). Certain games will vary in duration, but planning ahead and forming a routine will be beneficial in the long run to avoid overuse. A general rule of thumb is, the longer you play, the longer the break should be to allow for some recovery. )
Massage
- (Helpful at times whenever pain or tenderness is present)
Ice
- (Following long bouts of gaming if painful)
Heat
- (Prior to gaming sessions or stretches)
Relative rest
- (If tenderness becomes apparent over the back side wrist area shown above then it is best to reduce the time playing or take some added time off)
Sleep/Nutrition/Mental health
- (These underlie all of what is experienced in a day and cannot be ignored in injury prevention)

References

DeLuca, M. K., Cage, E., Stokey, P. J., & Ebraheim, N. A. (2023). Medial epicondylitis: Current diagnosis and treatment options. Journal of Orthopaedic Reports, 2(3), 100172. https://doi.org/10.1016/j.jorep.2023.100172

Galloway MT, Lalley AL, Shearn JT. The role of mechanical loading in tendon development, maintenance, injury, and repair. J Bone Joint Surg Am. 2013;95:1620-8.

McGee C and Ho K (2021) Tendinopathies in Video Gaming and Esports. Front. Sports Act. Living 3:689371. doi: 10.3389/fspor.2021.689371

Reece CL, Susmarski AJ. Medial Epicondylitis. . In: StatPearls . Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557869/

Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. American Family Physician. 2005;72(5):811-818