Game on: Orthopedists integrate esports into practice

Game on: Orthopedists integrate esports into practice

The world of competitive gaming, known as esports, has expanded over the years and is anticipated to continue growing, with viewership expected to increase from 435.9 million in 2020 to 577.2 million in 2024, according to market reports.

As interest in esports gaming continues to grow, it is anticipated that injuries among players will increase, as well. Although currently less common than traditional sports injuries, Caitlin McGee, PT, DPT, of 1-HP, said the frequency of injury treatment among esports athletes is not the best indicator of how common these injuries occur since many esports athletes may not seek treatment.

“We cannot say with absolute certainty how common esports injuries are, [but] we suspect that there are more of them than we have treated,” McGee told Orthopedics Today.

When esports athletes present with injuries, they tend to be overuse injuries identified usually in the upper extremity compared with the traumatic injuries identified in traditional athletes, according to sources who spoke with Orthopedics Today.

“For traditional athletes, there are several different sports where ergonomics and exposure time and microtrauma can also affect and cause injuries for them, but typically traditional sports athletes are more predisposed to high-impact, quick pivoting, more velocity and speed type of injuries where we honestly tend not to see too much of that in the esports group,” Dominic King, DO, sports medicine physician at Cleveland Clinic, said. “But overtraining is overtraining. So, in the same way that you can overtrain with football or basketball, you can overtrain with gaming.”

King said esports athletes who train or compete for more than 10 hours a day will frequently experience pain in their elbow, shoulder or wrist, as well as soreness of the neck and lower back.

“Occasionally, those can go on to develop into some other conditions that become a little bit more chronic and then the pain or symptoms are significant enough that they end up seeking true medical care and not just taking care of it at home,” King said.

Nina R. Lightdale-Miric, MD, director of the pediatric hand and upper extremity orthopedic surgery program at Children’s Hospital Los Angeles, said most injuries seen among adolescent esports athletes include nerve compression and repetitive tendinitis injuries.

Edward Rosero, MD, sports medicine physician at Rothman Orthopaedic Institute, said some esports athletes may also experience neurologic symptoms, such as carpal tunnel or cubital tunnel syndrome.

“Occasionally, you are going to see someone with a cervical radiculopathy or pain traveling from an irritated nerve root coming from the neck and going down into the arms or even the lower back, for that matter too, down to the legs,” he told Orthopedics Today.

Other injuries that esports athletes can sustain include De Quervain’s tenosynovitis and thoracic outlet syndrome, according to McGee. Esports athletes may also experience some degree of scapular dyskinesis, she said.

“In and of itself, a scapular moving weirdly is not a diagnosis. Is it functionally causing problems and is it connected to other issues? Then we start talking about whether or not your scapular dyskinesis means something,” McGee said.

When an esports athlete presents with a gaming-related injury, sources who spoke with Orthopedics Today stressed the importance of treating them and their injury the same way they would treat a traditional athlete. McGee said this includes gathering a comprehensive subjective history of the injury before moving on to an objective assessment.

“We will look at range of motion, we will look at strength, we will look at endurance a good deal of the time because that is a big part of [gaming] as opposed to just raw strength,” McGee said. “We will put them through clinical tests if that is appropriate. But, by the time we finish the subjective interview, we should have a good idea of what we are looking at and higher and lower suspicions for various types of injuries.”

King said that once a specific injury has been identified, treatment focuses on treating the microtrauma and optimizing ergonomics and the time that esports athletes spend playing.

“Some things that we will do is, for some gamers, we will switch them over for a short period of time from a traditional mouse to a vertical mouse,” he told Orthopedics Today. “The vertical mouse puts their hand and their elbow in a little bit more of a neutral position, puts a little less stress on the pronators and the supinator that rotate the forearm.”

King said they may also recommend different types of compression sleeves worn on the elbows or wearing a gaming glove that provides less friction between the hand and the mousepad. Ergonomic recommendations should also be provided on how to best position the computer monitor and how close athletes should be to the screen, he said.

“The same thing if it ends up being both of the wrists, or especially the wrist that is on the keyboard, making sure that they have a keyboard that is lifted up enough, that they are in a neutral position,” King said.

Esports athletes should also be evaluated in a gaming chair to learn the proper positioning and ergonomics that are needed while playing, he said.

McGee said it is also beneficial to have an esports athlete bring in their controller or device so the orthopedist can see firsthand what may be contributing to the injury.

“For example, when you have an extensor tendinopathy, it is not all that uncommon to see issues further up the kinetic chain at the shoulder because when you have that lack of proximal stability, you lose some of that distal mobility as well, which can result in a degree of tendinopathy over time and with other factors,” McGee said. “So, we make sure that we get a clear view of what exactly they are doing with their devices, if that is the area that we feel is contributing most to the injury.”

In addition to proper ergonomics, McGee said esports athletes should be educated about their injury and the factors that contributed to it, as well as what their recovery timeline entails. Coaches and support staff should also be aware of what structures need to be in place in terms of rest and stretching for the recovery of their athletes, she said.

“It works better when we get to work with an entire team ... and can set up structures for all the players. But when we are treating just one player, we will still integrate it with their team structure,” McGee said. “These players are young, a lot of them, and sometimes it helps to have a coach who reminds them aren’t you supposed to be doing exercises right now?”

Although Rosero said the majority of esports injuries can be treated conservatively with stretching and physical therapy, Lightdale-Miric said she has seen chronic, recalcitrant injuries, such as tendinitis and nerve compression, lead to surgery.

“These are injuries that would otherwise be treated with rest, some ice and compression, some occupational therapy, some even with bracing. If left untreated, they can go on to injuries that are career-ending,” Lightdale-Miric told Orthopedics Today. “The child can no longer participate in the sport, [the injuries] start affecting their schoolwork and their performance in their activities of daily living.”

To reduce the risk of esport injuries, sources who spoke with Orthopedics Today recommended esports athletes implement proper ergonomics before an injury occurs. This includes adjusting a young athlete’s gaming position over time as they grow, according to Lightdale-Miric.

“The goal of prevention is to look at ergonomics and your position while using the game and optimizing it to not only control for routine things, but, in addition, to recognize that you are a growing child and 1 year later the position that you were comfortable gaming in may be different,” she said.

Rosero said another form of prevention involves taking regular breaks during game time and employing a proper warmup or stretching routine for about 10 to 20 minutes in the beginning of the day to help maintain flexibility in the neck, wrists and shoulders.

“Just like any athlete, your body is a tool, so if you do not take care of it, it is going to wear down,” Rosero said. “Because a lot of the esports injuries are not acute injuries, they are more chronic injuries, there has been a paradigm shift to preaching prevention and stretching.”

Elizabeth G. Matzkin, MD, chief of women’s sports medicine at Brigham and Women’s Hospital, said routine exercise, including core strengthening, may reduce an esports athlete’s risk of injury.

“We absolutely know that they need to be working out and staying physically fit, just like any athlete that we treat, like runners, soccer players, football players,” Matzkin told Orthopedics Today. “They need to have a good, strong core, they need to maintain good posture, they need good rotator cuff strength to keep their shoulders in good alignment and then everything basically filters out from the core. It will decrease their risk of injury to their neck, their back, their shoulders, their elbows, their forearms, their wrists.”

In addition to reducing their risk of injury, routine exercise may potentially improve the athlete’s overall performance by providing better muscular endurance and the ability for the brain to focus and function, McGee said.

“We know that in the long-term both cardiovascular and aerobic and strength and aerobic training improve physical function and cognitive function,” she said. “We know that consistent exercise can lead to improvements in your attentional control, in your ability to tune out extraneous information and tune in to the relevant information, in your reaction time, in your ability to make decisions.”

Although orthopedic surgeons and sports medicine physicians are best equipped to treat, manage and prevent injuries among esports athletes, sources who spoke with Orthopedics Today said it is important for orthopedic surgeons to collaborate with other medical professionals regarding the overall care of esports athletes.

“We work closely with our physical therapists, sports nutritionists, the strength and conditioning coaches [and] sports psychology,” Matzkin said. “If they are sitting so much and they have poor bone health, perhaps we need to work with endocrine, but I think we would collaborate with similar specialties as we would for our traditional athletes.”

In addition, Rosero said it is important to partner with an optometrist and ophthalmologist due to the amount of time players spend in front of a screen.

“Aside from doing the yearly physicals and seeing an orthopedist if they have some ... musculoskeletal pain, so to speak, they should be having their yearly eye exams to make sure that their vision is adequate,” Rosero said.

As esports becomes more popular worldwide, Lightdale-Miric said more research is needed on a variety of topics within esports, because what is currently available in the orthopedic field is currently inadequate.

“Within the orthopedic surgery literature, it is rare to find a good study that shows you how an esports gamer is different than a tennis player or a violinist,” Lightdale-Miric said. “Yes, they are both hurting at the elbow where the extensor carpi radialis brevis inserts on the lateral epicondyle, but are their injuries the same? ... Just because it is the same findings on clinical exam, is there something more specific that we need to do because of the etiology?”

McGee said more research is needed on the prevalence and incidence of esports injuries. Once those are established, researchers can look at the impact of ergonomics and certain peripherals and positions on injury risk, she said. Not only do the diagnostic criteria for upper extremity overuse injuries need to be validated for esports athletes, but return to play protocols need to be developed for esports athletes, as well as appropriate practice structures, McGee said.

“Right now, we use a lot of the traditional performance training models, but those were developed in non-esports context. Do they apply in esports when you cannot necessarily break down everything you do in a game to a discrete skill and practice that single discrete skill?” she said.

Future research should also review the potential long-term consequences of esports gaming, according to Matzkin, who said comparisons are still needed on performance and outcomes between fit and unfit gamers.

“If someone is playing these games 10 hours a day, are they going to be a better gamer than someone who plays 8 hours a day, goes to the gym for 1 hour and works on strength and other issues?” Matzkin said. “How does that affect their quickness, their mental acuity and all those other things?”

It is important to look at the type of nutrition recommended for long play and calorie expenditure among esports athletes, King said.

“Even though you would [think] that [calorie expenditure] is probably pretty low, [it] actually can reach a high amount with the type of gaming that is done for some of these athletes, and especially when you get to active video gaming or extended reality, virtual reality type of gaming,” King said. “You are talking about the same types of injuries and energy expenditure as a lot of traditional sports athletes.”

As more esports athletes find their way into orthopedic practices and clinics, it is critical for orthopedic surgeons to take esports athletes seriously and not minimize their experiences, Rosero said.

“I know they are not playing basketball, they are not playing football, they are not playing soccer, they did not get tackled, they did not get hurt, but these are athletes, especially if they are athletes who rely on this as a profession,” he said. “The second you dismiss them as just an adult or someone just playing video games, you are going to lose that person. As physicians, we take an oath to treat everyone, and I think that if you start to dismiss esports you are going to miss out on treating a lot of people.”

McGee said orthopedic surgeons should be patient with esports athletes who may be skeptical or anxious working with them due to being dismissed in the past, as well as be patient with themselves as they learn to navigate esports injuries and the factors that contribute to them.

“You have a lot of years of experience and a lot of information about treating traditional sports injuries and you will have models and structures in your head that you are able to apply readily and easily to the patients that you work with,” McGee said. “We do not have those models and structures just yet for esports, so you are probably going to have to be a little more patient, both with yourself and with the patient that you are treating, as we figure those out.”

In general, Lightdale-Miric said, orthopedic surgeons need to become accustomed to treating esports athletes and realize that esports and professional gaming is not going anywhere.

“Injuries from competitive endurance gaming are here and here to stay,” Lightdale-Miric said. “Start participating in the musculoskeletal health of your patients who do it. Put questions about it on your intake health history sheet, discuss and research prevention and collaborate with the industry in order to protect and care for the growing number of children and adults who participate in esports," she said.

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