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Case Study: Esports Athlete Overcomes Ulnar Nerve Entrapment With Comprehensive Treatment

Rest is often not the best care for gamers’ overuse injuries

Asian male rubbing wrist while playing video game

A coach in a university esports program recommended that an incoming student athlete work with Cleveland Clinic Esports Medicine to address discomfort in his forearm and hand. For three months, the student, who would be attending the university on an esports scholarship, had been experiencing numbness and tingling in his left arm down to his little finger while gaming. He also reported some weakness in his left arm and hand when not gaming, while performing daily activities. 

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The discomfort compromised his quality of play, including speed and reaction time, and reduced his duration of play in his specialty, Rocket League.

“He couldn’t play for more than two hours without pain,” says Drew Schwartz, DC, a chiropractic physician and ergonomics specialist at Cleveland Clinic. “That’s a fraction of the time he would need to spend training and competing in college.”

Esports injuries are becoming more prevalent

Esports, or competitive video gaming, is fast growing. According to a 2022 position statement by the American Osteopathic Academy of Sports Medicine, more than 300 million people worldwide watch esports. The International Olympic Committee now recognizes competitive video gaming as an organized sport. The National Association of Collegiate Esports boasts more than 240 colleges and universities, 5,000 student athletes and $16 million in esports scholarships. More than 250 high schools in Ohio alone have esports programs, according to Esports Ohio, a nonprofit educational esports organization.

“As esports gains momentum and the number of participating athletes increases, the demand for specialized medical care in this field is also rising,” says Dominic King, DO, Director of Esports Medicine at Cleveland Clinic. “It’s imperative that the intricacies of esports athletes’ health concerns be integrated into the evolving landscape of sports medicine practice.”

Esports athletes are vulnerable to a number of overuse injuries, such as wrist and hand pain, neck and back pain, and vision fatigue, as well as nutritional and physiological stressors.

While esports athletes with overuse injuries often are advised to rest, “there are more factors to address,” says Dr. Schwartz. “Rest is usually not the best solution for these athletes. When the patient resumes play, their tissues will continue to be stressed and their symptoms will return.” 

Treatment requires multiple interventions

Following a complete evaluation (including patient history, physical exam, upper extremity nerve tension tests, and assessment of length and stress of soft tissues while in playing position), the patient was diagnosed with ulnar nerve entrapment at the wrist.

“We evaluated up the ulnar nerve pathway, to determine if pectoralis, levator scapulae or other muscles were contributing to the pain,” says Dr. Schwartz. “When gamers flex forward during intense play, for example, the anterior chain musculature is engaged, which often is the culprit in ulnar nerve entrapment.”

The patient’s treatment involved multiple interventions, including:

1. Ergonomic adjustment. “We encourage 90-90-90 posturing, where there’s a 90-degree angle from foot to shin, at the knee and at the hip,” says Jason Cruickshank, AT, an esports neurocognitive, strength and conditioning specialist. “Shoulders should be down and back. A chair should help support that position so you don’t lean forward, and your mouse and keyboard should be close enough, so you don’t bend to reach them. Armrests should support your forearm so you don't put all pressure on your elbow.”

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The patient was advised to use a desk to sit at a level surface and adjust the height of his controller during gaming activity to limit prolonged wrist flexion.

“We needed to promote extension in the patient’s body,” says Dr. Schwartz. “Even if he resorted to leaning or bending during a game, we advised him to reset his posture after a game, returning to an upright position to help offload stressed tissues.”

2. Soft-tissue mobilization. To release the nerve entrapment, Dr. Schwartz performed soft-tissue mobilization in clinic, focusing on musculature along the ulnar nerve pathway. The patient also was taught how to do soft-tissue mobilization on his own, using a lacrosse ball to promote tissue pliability and improve fascial gliding.

3. Decompression of cervical spine. “This was necessary due to the patient’s forward flexion of the head, a compounding force that contributed to the issue along the ulnar nerve pathway,” says Dr. Schwartz.

4. Kinesiology taping. Taping provided slight compression and improved stability for the extensors and flexors of the patient’s wrist.

5. Targeted exercise. An exercise program, incorporating hand weights and resistance bands, was designed to help the patient increase load capacity of flexors and extensors in the wrist while also improving scapular/cervical biomechanics, enabling him to play longer gaming sessions.

“His extensor group would be stretched during play, so we needed to make those muscles more comfortable in the lengthened position,” says Dr. Schwartz. “We also introduced modifications to the patient’s daily activities to help keep those tissues pliable and encourage blood flow.”

After four visits over two months, the patient was advised to continue exercises on his own, including performing warm-up exercises before gaming. With continuing self-care, the patient has been able to sustain an intense esports schedule at the collegiate level without any pain.

Gamer’s Health Guide outlines comprehensive care

“Esports injuries must be addressed holistically — not only with rest, but with comprehensive care that treats the whole gamer,” says Dr. King. “Such inclusive care is equally as beneficial for those who game as a pastime as it is for competitive esports athletes.”

Dr. King and his colleagues in Cleveland Clinic Esports Medicine recently published the Gamer’s Health Guide, which provides guidance on gaming ergonomics; stability, mobility and posture for gamers; cardiorespiratory fitness; nutrition; mental health and more.

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“Competitive video gaming is no longer a fringe thing,” says Dr. Schwartz. “It has become mainstream, a billion-dollar business, and it’s growing with younger populations. Providers need to be aware of it so they can better care for patients involved in esports.”

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