HOW TO TAKE DOWN A GAMER'S ELBOW…The Lateral Epicondylosis

The prevalence of injuries in eSports has become a major drawback for the sport. More and more video gamers are experiencing the effects of a static posture and long hours full of intense fights. Although not as much as the injuries to the wrist and the hands, injuries to the elbow should still be something to worry about, since the shoulder, the elbow, and the hand work as a unit, providing the range for arm movements and a stable base for the forearm, hand and wrist motions. Lateral epicondylosis is one of those elbow conditions that has been frequently encountered by gamers and often a cause of withdrawal from a game.

Relevant Anatomy of the Elbow: The Lateral Epicondyle

Your elbow is made up of three bones: an upper arm bone or the humerus, and two forearm bones, the radius and the ulna. Your humerus ends at your elbow with two bony bumps on both sides, the medial epicondyle on the inside and the lateral epicondyle at the outside.

The lateral epicondyle is the bony prominence on the outer side of your elbow where several muscle tendons of the forearm are attached to, collectively termed as the common extensor tendon, which serves to extend the wrists and the fingers. The following are the muscles that extend your wrist with their other functions:

• Extensor Carpi Radialis Brevis(ECRB): radial deviation of your wrist (movement of the wrist toward the thumb side)
• Extensor Carpi Ulnaris: ulnar deviation of your wrist (movement of the wrist toward the pinky side)
• Extensor Digitorum: extension of your four fingers
• Extensor Digiti Minimi: extension of your little finger

The Extensor Carpi Radialis Longus attaches slightly higher to this area, specifically at the lateral supracondylar ridge, and shares the same function as the ECRB, that is, wrist extension and radial deviation. Another muscle associated with this bony projection is the Anconeus, which has the same attachment site as the ECRB but functions as an elbow extensor, together with your triceps. The anconeus also functions as an elbow stabilizer during forearm pronation movement (inward rotation of the forearm) in which your forearm rotates towards your body so that your thumb points directly to you.

In lateral epicondylosis, the area where maximal tenderness is usually felt is a spot lower than the common attachment of the extensor muscles of the forearm. The most commonly involved tendon is the ECRB, but other tendons may be affected because of the proximity.

The Biomechanics of a Gamer’s Mouse Elbow

To racket players, lateral epicondylosis is known as the tennis elbow and is a condition associated with repetitive stress to the common extensor tendon from the powerful backhand stroke. To video gamers, this is known as the mouse elbow, referring to the overuse of a computer mouse, particularly in PC gamers. Repetitive finger motion, frequent wrist extension, or when the wrist is held in extension when using the mouse for long periods can strain the muscles of the forearm and develop pain in the area of the lateral epicondyle. Studies show that mouse elbow is often due to the damage to ECRB, the muscle that stabilizes the wrist when the elbow is straight, particularly in cases where the muscle is activated as it elongates (eccentric contraction). The ECRB is weakened from overuse and irritation, microscopic tears form in the tendon, leading to elbow pain. Although lateral epicondylosis has been identified as an inflammatory condition, inflammation is only present in the early stages of the disease and painful symptoms are usually felt when the condition has already progressed to a degenerative state due to “wear and tear,” causing the affected tissues to undergo a reduction in blood flow and scar tissue formation, a process known as angiofibroblastic tendinosis.

The ECRB is also prone to be affected because of its position. As the elbow bends and straightens, the ECRB rubs against the bony spot.

How to Know If You’re Experiencing a Mouse Elbow

The most common complaint by gamers with lateral epicondylosis is a gradual onset of pain and tenderness over the lateral epicondyle, which can radiate up along the upper arm and down into your forearm and wrist. A decrease in flexibility and strength of the wrist and hand muscles are also often seen.

Common signs and symptoms of a gamer's elbow:

• Pain on the lateral epicondyle
• Tenderness at ECRB insertion
• Weak grip strength
• Limitation of motions due to pain
• In severe cases, pain at night
• Pain with gripping activities, such as holding a racquet, turning a doorknob, or shaking hands.

The following provocative maneuvers reproduce pain at the lateral epicondyle:

• Cozen’s Test: resisted wrist extension with wrist radially deviated, forearm pronated, and elbow 90-degree flexed
• Maudsley’s Test: resisted extension of the middle finger while palpating the lateral epicondyle
• Mill's Test: passive forearm pronation and wrist flexion while extending the elbow

How to Treat a Gamer’s Mouse Elbow

Among the most important of the early management of lateral epicondylosis is withdrawal or avoidance of the activities that cause the symptoms. This ensures that the condition is not aggravated and appropriate treatment can be given safely and effectively.

ACUTE (IMMEDIATELY AFTER THE INJURY):Management is geared toward relieving the elbow pain. The RICE (rest, ice, compression, and elevation) protocol can be helpful to relieve pain at the initial stage.

• REST: Stop playing. Rest, modification, or avoidance of triggering activities usually leads to pain relief. While resting is advised, total resting is not ideal. A counterforce brace can be used to relieve the tension on the epicondylar attachment, as well as control the amount of wrist extension to prevent the occurrence/aggravation of symptoms and to facilitate repair.
• ICE: Cryotherapy or icing the area three times a day for 3 to 5 minutes per session reduces pain and acute inflammation.
• COMPRESSION: Compression using a bandage or a specialized garment that provides both cryotherapy and compression simultaneously can help alleviate pain and swelling if present. A counterforce brace is again appropriate to relieve symptoms while controlling the swelling.
• ELEVATION: Elevation if there is edema of the wrist or fingers to encourage fluid drainage from the injured site.
• ANTI-INFLAMMATORIES: Nonsteroidal anti-inflammatory medications (NSAID), like ibuprofen and naproxen, are often prescribed to relieve pain and help control inflammation.
• CORTICOSTEROID INJECTION: If the patient doesn’t respond to conservative treatment and NSAIDs, corticosteroid injections may provide intended relief.

REHABILITATION AND PREVENTION:Rehab goals include maintaining or improving the flexibility and strength of the wrist and finger extensors, as well as the related muscles, and preventing the recurrence or onset of the condition. Frequent stretching along with high‑repetition, low-resistance exercise program can help with deal with elbow pain from lateral epicondylosis.

1. Friction Massage– Friction massage aids in recovery by activating the body’s tissue repair mechanisms. It promotes increased blood flow and soft tissue extensibility. With your thumb, gently apply a back-and-forth stroking over the tendon at the point of greatest tenderness, perpendicular to the tendon fibers (cross-fiber) for 1 to 2 minutes.
2. Stretching Exercise– All patients are instructed to stretch the wrist extensors even with no flexibility deficits. Stretching can provide pain relief by releasing tension on the wrist extensor muscles and improving blood flow to the area.

•  WRIST EXTENSOR STRETCH WITH ELBOW EXTENDED

Extend your arm in front of you with elbow straight, forearm rotated inward (palm facing down), and your shoulders pulled back. Curl your fingers down and with your free hand, push the back of the affected hand down and pull it towards your body. Hold for 15-30 seconds and repeat three times.

• WRIST EXTENSOR STRETCH WITH ULNAR DEVIATION

Follow the procedure as above but turn your forearm more into pronation with your thumb pointing the floor. Feel the stretch and hold for 15-30 seconds.

• TABLE STRETCH FOR LATERAL EPICONDYLOSIS

This is a variation of the above stretches. Stand in front of a table and place the back of your hand against a tabletop with a straight elbow. Hold for 15-30 seconds.

3. Strengthening Exercise – Attention is given to the eccentric strengthening of the wrist extensors.
   • Rest the affected arm on the table with your forearm turned inward and palm facing the floor.
   • Hold a weight in your hand and allow your hand to hang off the edge of the table.
   • With your free hand, bend the affected wrist into extension while lifting the weight.
   • Gradually lower the weight into wrist flexion.
   • Repeat 10 to 15 times for three sets.

Preventive Measures for Mouse Elbow

PC gamers’ mouse and keyboard tray are the usual cause of mouse elbow because it put their arms in almost static, tensed postures for long periods, straining the tendons at the outer elbow. Apart from performing the simple exercises mentioned, the following ergonomic adjustments can also be made to address this issue and reduces the risks of acquiring a mouse elbow:

• CHECK YOUR STATION:Adjust your seat height so that your wrist is kept in a neutral position while holding the mouse. Too low a seat height will cause your wrist to flex more while too high will cause it to extend further.
• KEEP YOUR KEYBOARD FLAT:This reduces the amount of wrist extension, which can aggravate the symptoms of mouse elbow. Try choosing keyboards with a low, neutral profile where the function row is about the same height or lower than the space bar.
• USE A VERTICAL MOUSE:This allows the gamer to operate the mouse with the wrist in a more relaxed position. It reduces both the extension of the wrist and the twisting of the forearm (pronation).

Soft Tissue Mobilization: Recover like a Pro with Recovapro

Avoid lateral epicondylosis with Recovapro. A variety of soft tissue mobilization techniques can be applied using Percussive Vibration Therapy by Recovapro. Goals include reducing lateral elbow pain, promoting faster tissue healing by increasing blood flow, and increasing soft tissue extensibility.

Note:Terms used to describe the techniques are just for reference and comparison to actual manual therapy. The procedures are presented as if a manual massage is applied using the Recovapro massage gun.

• With the round-head attachment, a deep friction techniqueis performed by gliding the Recovapro massage gun in small circular movements across the common wrist extensor tendon at the outside of the elbow. Use light pressure at a lower intensity, preferably 1 or 2, to increase blood flow and desensitize the area for a more thorough workup. Stay for 15 to 20 seconds before proceeding.
• Glide the Recovapro massage gun along the muscle belly of the wrist extensors to promote relaxation and increase tissue extensibility. Apply cross-fiber, longitudinal stripping, and compression broadening using a higher intensity, preferably intensity 3, at moderate pressure.
• Perform active-release technique by moving the forearm into pronation and supination, and the wrist into various positions. Keep the gun over the areas of maximum tenderness with increasing pressure until tension release is felt.
• Finish a session at a maximum of 90 seconds and repeat twice daily.

PRECAUTION: avoid the bony prominence while using the massage gun. This may cause discomfort and may aggravate the condition.