Electronic sports (esports) have grown into a multi-billion-dollar industry, generating upwards of $1 billion in revenue and 450 million viewers in 2019 alone.

Total tournament earnings by professional competitors that same year was a quarter of a billion dollars.

Collegiate institutions now offer varsity esports programs and esports scholarships, while the various branches of the US military have established competitive esports teams of their own.

The International Olympic Committee has begun to discuss the inclusion of sports-simulation esports games in future Olympic events.

By any metric—participation, viewership, or financial— the esports industry is established, substantial, and still growing.

However, the esports industry lacks the wealth of medical research and the established healthcare infrastructure available to its traditional sports counterpart.

While many traditional sports athletes remain competitive into their 30s and even 40s, esports competitors often retire before reaching their 30s.

Anecdotally, overuse injuries are common, although limited research exists to establish precise prevalence data.

Several well-known, relatively young (18–25-year-old) players have had to take significant time off or even retire due to injury.

In a number of cases, prolonged periods of misdiagnosis or lack of any diagnosis at all have contributed to those early retirements.

Chinese League of Legends star Jian ‘Uzi’ Zihao retired at 23, citing chronic shoulder pain in his mouse arm.

Nineteen- year-old Fortnite competitor Issa ‘Issa’ Rahim retired after just two years of competition due to a wrist injury involving nerve damage.

Clinton ‘Fear’ Loomis, who was diagnosed with lateral epicondylalgia and a radial nerve compression injury for which he took a year off to receive treatment, is one of the few players to successfully return to play from an overuse injury in esports.

A common thread in discussions with players about these injuries is a pattern of seeking care from a variety of professionals, most of whom have limited experience treating casual, let alone competitive, gamers.

Competitors report being told to rest, wear a brace, and ‘just play less’. This, in turn, feeds an entirely mistaken belief among esports competitors: injuries are inevitable if you play enough, and in most cases, you cannot recover from injuries.

This stands in sharp contrast to the experience of most traditional sports athletes, who accept injuries as inevitable but manageable. This experience is contextually shaped by the robust healthcare infrastructure which exists to support traditional sports.

Inevitably, when discussing esports and traditional sports, questions are raised: are esports actually sports and are esports competitors really athletes?

Given that esports share more in common, in terms of biomechanics, with office work than with football or rugby, both are reasonable questions when it comes to classifying esports.

These questions, however, miss the more relevant considerations for determining the role of physiotherapists in this industry; namely, that esports competitors have unique injury concerns and performance considerations based on their specific physical and cognitive demands.

 The role of physiotherapy

Physiotherapists are well positioned to address these concerns and considerations, particularly in this nascent stage of what can be referred to as esports medicine.

In the absence of sufficient research, practitioners must rely primarily on general musculoskeletal and orthopaedic principles, supplemented by research findings in analogous fields.

Musculoskeletal management

The management of musculoskeletal injuries is the first role that comes to mind for physiotherapy.

Upper limb tendinopathies, neck pain and back pain appear to be the most common musculoskeletal injuries in esports; however, detailed prevalence data is lacking.

According to a 2018 published survey of 65 collegiate esport players across the US and Canada, neck and back pain (42%) was most common, followed by wrist pain (36%) and hand pain (32%).

This was similar to a 2020 study of 188 Danish esport athletes, which also reported low back (31.3%), neck (11.3%) and shoulder (11.3%) pain being the most common; however, head (8.8%), forearm (7.5%), wrist (6.3%) and hand (5%) pain were also reported.

In our 2020 general esport clinical data at 1 Heath Providence, of 132 musculoskeletal conditions managed, the wrist/hand was the most common (66%) followed by the shoulder (18%), neck (6%) and low back pain (5%).

Specifically, the most common conditions were extensor digitorum tendinopathy, flexor digitorum superficialis/profundus tendinopathy, and de Quervain’s (abductor pollicis longus, extensor pollicis longus/brevis).

While there were some cases with ulnar nerve entrapment symptoms, there were no cases with symptoms consistent with carpal tunnel syndrome.

Carpal tunnel syndrome is a condition that is commonly quoted to be highly prevalent in both office workers and video gamers on social media and websites, but no data has supported such claims.

The prevalence of musculoskeletal conditions in esports alone warrants the need for physiotherapy management of these athletes, and successful management is based on the first principles of musculoskeletal care in addition to a specific understanding of the athlete’s movements and activity demands.

Based on the available data, it is safe and logical to assume that most musculoskeletal conditions in esports are mainly the result of overload.

With the exception of virtual reality games, athletes are mostly stationary in their seats, and therefore unlikely to have a high-impact mechanism of injury such as a fall.

Of course, other exceptions apply, such as accidently throwing the (Wii remote) controller at someone else, but these instances are fortunately much rarer!

As most musculoskeletal conditions in this population are related to overload, load management is key.

Like traditional sports, it is not just how much one trains in one sitting, but duration and frequency over time. This varies between levels of play.

For example, a semi-competitive player might only play a few hours a day in a ‘pick-up game’ format, while professional players may play pick-up games, ‘scrims’ (organised practice games with other professional teams) and tournament matches.

Like traditional sports, on and off session schedules for professional players need to be considered.

Unfortunately, esports has what is called a ‘hustle and grind’ culture, where professional players may sometimes play up to 16 hours a day to practise skills, play scrims and matches.

This is based on the misconception that playing hours on end is the best way to acquire new skills and perform well. Instead, it decreases both cognitive and physical performance and increases risk of physical injury.

This problem is compounded by the fact tournaments often start in the evening. Therefore, game practice often runs from the afternoon into the night, with many sleeping as late as 3am.

Nevertheless, load management also involves a deep understanding of the game platform and title that the esport player plays.

In general, for PC games, first- person shooter games (Counter-Strike) involve more mouse movement, while real-time strategy (StarCraft) and multiplayer online battle arena (League of Legends) require more keyboard movement.

At the professional level all these types of games have at least three times more movements per minute (also known as actions per minute) than office workers.

Console, mobile and virtual reality games each have their biomechanical considerations as well. Another way to manage load is the consideration of posture and ergonomics.

The adoption of ergonomics in gamers has mostly repeated the history of ergonomics in office workers, with many technological companies claiming the ‘ergonomic’ stamp of approval with their many types of different controllers, mice and keyboards.

This is based on an incorrect assumption that there is a ‘perfect posture’ that everyone should adopt, which ignores the fact that there are biomechanical differences between individuals.

Nevertheless, general principles of ergonomics are effective in managing players who already present with pain, as immediate effects on pain and tolerance can be obtained.

These include, but are not limited to, monitor height, tilt and distance; keyboard position, tilt, and hotkey bindings; mouse size, weight and grip style; chair backrest angle and height; armrest angle and height; seat cushion firmness and height; and, of course, the height of the desk itself.

But, as for general musculoskeletal populations, evidence for posture and ergonomics as a preventative intervention is lacking.

Musculoskeletal prevention and performance

Prevention of injuries in esports is another role for physiotherapy.

While injury prevention programs for esports have not been established, key concepts borrowed by traditional sports, such as play scheduling, strengthening of the muscles for task-specific movements, and maintaining adequate physical activity levels, are all reasonable factors to address with the current evidence available.

The lack of physical activity has been a stereotype for video gamers, as depicted in various cartoons.

While there may be some truth to this, many professional esport players do understand the importance of physical health and are open to do what it takes for them to gain a competitive edge.

Many do need guidance in this area, especially in regard to play time scheduling. Non-competitive players, on the other hand, vary in their understanding of the benefits of physical activity.

Overall, both populations need to understand that being fitter has cognitive and physical performance benefits, which is often the selling point.

Holistic health

Finally, physiotherapists in this rapidly emerging field may also be in the position to provide general health interventions or be the point of contact for referral to other health professionals.

It is currently common for esport organisations to have only a single health professional (ie, solo physiotherapist) managing several teams.

Such a physiotherapist in this position would be wise to look beyond the athlete’s physical health and monitor their mental health, sleep, and diet.

Hopefully as esports continues to grow, more funding is invested in a multidisciplinary healthcare team for players. At present, relatively few teams have such infrastructure available to their players.

To overcome this widespread lack of infrastructure, identifying existing barriers to implementation is paramount.

Existing barriers

Several barriers exist to the widespread implementation of the health and performance infrastructure typically associated with high-performing competitors.

Some of these are relatively straightforward logistical or financial barriers; such barriers are not exclusive to esports.

Other barriers are more cultural in nature, including the hustle-and-grind culture present in the relatively nascent esports industry, limited understanding of appropriate training periodisation, scepticism of the role of medical care in reaching or maintaining peak performance status, a significant lack of research to inform best practices, and the prevalence of misconceptions among players and staff.

As alluded to previously, misconceptions regarding health, performance, and injury significantly impact player perspectives of health and performance professionals.

Lacking the intramural, club, and varsity developmental tracks available in traditional sports, few players have the opportunity to interact with medical practitioners prior to attaining professional status.

Of those who have been seen by medical professionals, many lack positive experiences to report.

Individuals we have treated often report being told that their only option is surgery, that they will need to take significant time off or wear a brace permanently, or that they should just play less.

These reports are filtered through individual perceptions, but a consistent narrative thread emerges regardless of any potential bias from players: the majority of medical practitioners they interact with are inadequately prepared to address their specific needs.

At the same time, many players are inadequately prepared to be receptive to medical care. This mismatch can only be overcome by educating both parties and an increased emphasis on developing a rapport between patient and provider.

Physiotherapists are among the providers best equipped to develop such rapport, given the extent to which we incorporate a biopsychosocial model into our education and treatment methodologies.

We suggest that while a multidisciplinary model of healthcare is necessary in esports, physiotherapists are particularly well suited to contributing to the field of esports medicine. 

Call for more clinicians and research

Esports is rapidly growing, whether some like it or not. We need physiotherapists who are well versed in video gaming to manage the health of players across all levels of play. But how does one get involved in the esports industry?

The cliche of via social media and networking does not fail here.

The competitors, professionals, and audiences of esports run wild across platforms such as Youtube, Twitter, TikTok, Discord and Twitch, which have been the avenues in which 1 Heath Providence has reached out with varying degrees of success.

Presentations to esport leagues and organisations are the next steps—before you know it, you could be consulting for players and teams.

More importantly, we need research in the field which then can inform guidelines for the prevention and management of musculoskeletal injuries in this population. At present, we rely significantly on analogous fields of research to inform best practices.

Potential sources to draw from include research on cognition and performance in air-traffic controllers; on sleep and performance in third-shift workers; on exercise, sleep, nutrition, injury prevention, injury management, and performance in traditional athletes; and emotional regulation, travel management, and performance in musicians, to name a few.

Earlier we presented what we believe are the typically common injuries and the ways to manage them, but research data to support these claims are needed.

Lastly, we are eager to chat further with anyone with an interest in esports. Find out more here or on Twitter: hpforgamers, CaitMcGeePT, kev_physio.

Dr Caitlin McGee (MS, PT, DPT), 1HP Esports Medicine Director, has been working in esports medicine for six years and is co-editor of the upcoming Handbook of Esports Medicine.

Dr Matthew Hwu (OCS, CSCS, DPT), 1HP President and Health Educational Content Creator, has been working with professional esport organisations for seven years, including contracts with Counter Logic Gaming and Los Angeles Gladiators/Guerrillas.

Dr Kevin Ho (PT, PhD), Associate Lecturer in the Discipline of Physiotherapy at The University of Sydney and 1HP Research Lead and esports physiotherapist, has been practising in the musculoskeletal field for eight years.