Path of Exile

A Guide to Hand and Wrist Injuries, and What You Can Do To Prevent Them.

So there's been an increase in discussion recently about hand and wrist injuries related to Path of Exile. A lot of this discussion is centred around things like the legality of using flask macros, the volume of loot dropping, and generally the amount of clicking that has to go on in game.

While these are all useful discussions, they're also entirely on GGG's end to influence. I thought it might be worth the time to take a somewhat different approach, and try and provide some insight into what might be causing hand/wrist pain for people, and what we as players can do to try and address this from our end.

Just a quick 'warning': there will be quite a bit of info below around the 'what' and 'why'. I strongly believe, and I've found in practice, that the more a patient knows about an injury, the better they're able to manage it, and the faster and more complete their recovery.

A bit of background on myself first: I'm a physiotherapist (physical therapist, if you're American), working in private practice, with a primarily sports focus. I work regularly with professional athletes, as well as with the general public. While I'm not specialized in hand therapy, I do have plenty of clinical practice in managing hand and wrist injuries.

With that out of the way, let's go over the basics of what might get injured and why, and some factors that make PoE more of a risk factor for hand/wrist injuries than other games.

What is a tendon?

Tendons are best thought of as the ropes that connect muscles (the structures that contract and produce force) to bone (the solid framework that gets moved). Your tendons are living tissue, so unlike a rope they can repair if they're damaged. Muscles in your forearm are fairly short, with long tendons that run into the hand. If you look at your forearm, and wiggle your fingers, you'll see the muscles contracting up near the elbow. For a muscle to produce movement, it (either the muscle itself or the tendon) need to cross over a joint. In the case of your hand, these tendons cross several joints as they run into the fingers.

Long, thin tendons crossing multiple joints means that these structures are a bit more vulnerable to damage than, say, a short, thick tendon like your triceps tendon, at the back of your elbow.

What causes tendon injuries

Short answer is: too much load. Longer answer is: still too much load, but that can happen in a number of different ways. A typical tendon tear will be caused by a very high peak load that exceeds the capacity of the tendon; basically too much force, and it breaks. This might be common in sports like Rugby or Football, where we see things like hamstring tears, but if you're getting traumatic tears from PoE, then you're doing something wrong.

The types of tendon injuries that are more common with PoE, and gaming in general, are caused by fairly high load, over longer periods of time. Remember before how I mentioned that, unlike a rope, a tendon is a living structure? Well as a living structure, it has to be maintained. Your body is constantly breaking down old or damaged tissue, be it tendon, muscle or bone, and is replacing it with new, healthy tissue. If you're putting quite high load on a structure over a long time period, then you can start to cause a bit more damage than your body can keep up with repairing, and so the balance between that breakdown and build-up gets disrupted, and leans more toward the breakdown side of things. This can weaken the structure, and can later lead to pain and injury.

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Why is PoE in particular rough on tendons?

Lots of clicking

There's a number of factors that contribute to PoE's higher risk of injury. One of these is quite obvious: there's a hell of a lot of clicking. Everything in game involves a lot of clicking. From moving, to using flasks, to picking up loot. There's just a lot of inputs in any given space of time. More than a lot of other games. This one's quite obvious, so I won't go into much depth here, other than to say that all that clicking adds up into a great deal of total volume.

Long, unbroken sessions A somewhat less obvious aspect to this is that there's also a lot less downtime in PoE compared to other input heavy games. This gets more true as you get more invested into the game. In something like LoL, you've got downtime between games and you've got periods of lower activity in game. In PoE, optimizing gameplay is all about minimizing downtime. The less time spent killing things, the better. When you're not killing things, you're clicking to pick up the hundreds of things that they dropped, so that you can buy things that will help you kill more things, faster. PoE play sessions also tend to be longer. The grindy nature of the game lends itself to longer sessions, and even a casual player might have 2-3 hour play sessions (which might not sound like a lot, but it IS a lot, and the fact that it doesn't sound like it says a lot about how much most of us play). Long, uninterrupted sessions of a (comparitively) high load activity, again, contribute to PoE's high total volume of load.

Season format

Now, this is something I haven't seen discussed, and I feel that it's one of the stronger contributors to why PoE players have issues with hand/wrist injuries. To be fair, the concept in play here is a little more advanced than 'clicking lots is bad'.

I'm going to bring us back again to 'tendons are living tissue'. A really important concept to understand here is that of tissue adaptation; basically, your body will adapt to be able to handle the loads that you place on it. That's the principle behind strengthening (lift heavy stuff, body grows muscle to be able to lift that better, we increase the load to make to body continue to adapt, and get stronger), and that's where it's most visible, but it applies just as much to other structures too. We see a significant increase in tendon injuries around the start of sports seasons, or when there's something like a marathon coming up. Lots of people who haven't done much in a while, suddenly jumping into heaps of training. The thing is, that you've just increased the demand on your tissues by a lot, and it hasn't had time to adapt to that yet. Your body isn't just going to keep resources tied up in maintaining strong muscles and tendons if it doesn't need to. So if your training/exercise load drops off a lot, for a longer period, then you'll lose some conditioning. It then takes some time for that to build back up again. This is why we always taper training for our athletes when we're coming off an off-season, and why it's important to maintain a decent level of training during this off season (if you're still doing quite a bit, but not as much as during the season, then we don't get nearly as big a fall off of conditioning, and it helps a lot in reducing injuries).

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Hopefully you can see why this is an issue with PoE. Most of us play like madmen for the first month or so of a league, then drop off hard, and don't play PoE again for another 2 months. Even if you are playing other games in the off-season, then they'll likely be much lower load, or quite different in their loading profiles. So at every league start, you're hammering your poor tendons, and they're struggling to keep up you you suddenly demanding that that keep up with 200+ apm for 8+ hours without a break. Unsurprisingly, they're sometimes not going to respond well to that, and it puts you at much higher risk of injury.

Non-PoE specific stuff

More general factors that often contribute to hand/wrist injuries are things like ergonomics; poor positioning of mouse and keyboard place extra stress on wrists, and create additional pivots/points of stress for tendons. General fitness and wellbeing plays an enormous role here too. If you're out of shape, you're far more likely to be injured. That goes just as much for those of us who drop weight and get super skinny if we aren't regularly exercising, as it does for those who go the other way, and put on a lot of weight. Sleep is incredibly important too. Sleep is where most of your tissue repair happens, so lack of sleep is a huge risk factor for injury.

So what can you do to minimize your risk of injury

I could go into specifics here for an age, but given that I'm already straying into novella territory, I'll try and keep this a bit more general.

Reduce overall playtime/take breaks

The best thing that you can do is to decrease your overall load. There's a number of different levers to pull to adjust that. The most obvious, and probably most impactful is to reduce overall play time. That could be reducing play session length, but the more realistic, and better-feeling way to do it is to take more regular breaks. Take a short 2-3 min break every half hour, and a longer ~10 min break every hour or so. It makes a big difference. Overall though, if you're having wrist issues playing PoE, you're playing too much. Drop back a bit and let things settle down. You're (probably) not being paid to play, there's no reason to injure yourself doing something that's supposed to be fun.

Condition yourself before league start

The other big change that could make a difference to a lot of people is probably going to sound quite counterintuitive. That's to play more in the week or two leading up to season start. Just like we'd gradually increase someone's running if they were training for a marathon, you'll do yourself a lot of good by gradually increasing your play-time in the lead-up to league start.

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Let me be clear, I'm not saying 'start mapping like a madman two weeks earlier', I'm just saying 'don't come into league start and play 10 hours a day after not playing an ARPG for 2 months'. Obviously, the ideal here would be to gradually increase your play FROM league start, and build up over a few weeks, but that's not how the game works, and it's not useful advice to many players.

A good way of easing back into ARPGs is to play something that isn't PoE for a week or so. Blasphemous, I know, but you're getting similar loading patterns in quite significantly lower volumes. Try out Last Epoch maybe, or the new D3 season started last week, so maybe hop into that for a bit of mindless fun.

Giving yourself a bit of time to condition before league start can make a big difference.

Look after yourself outside of the game

The advice that you'll see given most often is to stretch more. While this isn't wrong, it's also not the be-all-and-end-all when it comes to injury prevention. Yes, you should be going wrist stretches regularly. Everyone should be stretching more. Hold your stretches for a minimum of 30 seconds (time it on your watch/phone, because it's longer than you think), and if you think you're stretching enough, then double the number of stretches anyway. Stretching isn't magic, and it doesn't replace anything that we've talked about above, but it does help, and it is important. (And you're not stretching enough!).

Make sure you're eating well, at all times, and especially during league start, and getting enough sleep. You're asking a lot of your body to keep up with the increased tendon load, so the least you can do is ensure that it has enough time and resources to try and keep up with your manaiacal early-league HH farming.

In summary

While there's plenty of changes that GGG could make to the game to reduce physical demand on players, that's not something that we have control over. So it's even more important that we're aware of, and willing to work on, things that we as players can do to help minimize our risk of injury. Hopefully this can give you a bit of insight into what some of these things might be, and maybe help a couple of people protect their hands a bit more in the coming weeks.

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