Esports: Competitive gaming and its health implications

“I’m going to flake and take a nap; lemme host Milk. But I’m going to stream for 14 hours tomorrow, nooooo kyaaaap. Thanks for watching everyone, see ya.”

My favorite Twitch streamer ended his 12-hour stream one day with these ambitious words. And he was ready to do … 14 more? “Streaming” simply means live-recording for an audience (whether it be video games or in real life), and Twitch is a popular streaming platform where millions of viewers tune in daily to see their favorite streamers. I (Tim) streamed as a part-time hobby, but after playing for even eight hours, I didn’t want to touch another game for days.

And yet, there are people who play games for countless hours daily. Some are full-time streamers, making their living from subscribers, advertisements or donations from viewers. Others even find careers in professional gaming, playing in front of crowds of hundreds or thousands of people and even more watching online.

More than just a game

The concept of esports has changed and expanded vastly over the last five years, to the extent that it has become an industry. The term refers specifically to competitive play; so while all esports is gaming, not all gaming is esports. Popular titles such as League of Legends, Valorant, StarCraft, CS:GO and Dota have millions of players daily.

In countries such as South Korea and China, internet cafes are full of people who may not have the equipment at home to play their favorite games. In the United States and Canada, several schools have formed varsity teams and even offer scholarships to players seeking careers in professional gaming.

Many games also have professional leagues. Teams in regions all over the world compete yearly for the honor of representing their region in the world championships. In 2021, millions of viewers watched the League of Legends World Championships, with a peak viewership of over 4 million on Nov. 6, 2021 for the finals.

Who or what were these people watching exactly? EDG versus DWG KIA, two teams of five players that have beaten every team before them, and now competing for the ultimate title of world champion and the glory of lifting the Summoner’s Cup.

Esports players are commonly perceived by the public as sedentary young adults who should be out and active rather than sitting in front of a computer screen for hours every day. However, we would be remiss not to acknowledge the amount of cognitive effort and physical training they put into honing their skills, or the injuries that they may sustain while doing so.

Like other athletes, esports professionals dedicate many hours to their games. Per a recent study conducted by sports medicine physicians at New York Institute of Technology College of Osteopathic Medicine (NYITCOM), collegiate varsity esports players train from three to 10 hours per day.

Pros on higher-level teams such as Cloud9, Fnatic and T1 train even longer, dedicating over 40 hours per week to practicing as teams while in season, and additional hours to improve individually. Many also stream on Twitch during their “downtime” for continued practice or simply for fun and to interact with their fanbases. This results in esports athletes spending the majority of their days sitting in front of monitors moving just their arms and hands.

Esports health issues: Common injuries

Through their study, the NYITCOM physicians found that the most common complaints in the surveyed collegiate athletes included eye fatigue (56%), neck and back pain (42%), wrist pain (36%) and hand pain (32%). Esports players stare at their monitors (often two) for hours a day, following the movements and actions of the characters they are controlling; doing so often results in eye strain and/or temporarily blurred vision.

Posture also plays a critical role, as prolonged sitting can contribute to neck and back pain and increases the risk of developing chronic venous insufficiency and deep vein thrombosis (DVT). Overuse injuries involving the upper extremities are also common in esports athletes, given that many games involve rapid or continuous mouse movements coordinated with the appropriate buttons on the keyboard.

Constant stress on the wrists and hands, although seemingly harmless initially, can lead to intersection syndrome and tendinopathies such as lateral epicondylalgia over time (interestingly, players are often misdiagnosed with carpal tunnel syndrome and subsequently mistreated).

Former Cloud9 star and shotcaller Hai “Hai” Du Lam attributed his worsening wrist pain as a contributing factor to his initial decision to retire from professional League of Legends in 2015. Hand and wrist injuries plague many other professional gamers, who often end up wearing braces or being substituted out due to the pain.

Importantly for many esport athletes, time spent gaming comes at the expense of getting adequate daily physical activity, sleep and nutrition. This further increases their risk of developing chronic illness throughout and beyond their careers.

What we can do to stay healthy in the game (of life)

Educating our patients (gamers and non-gamers alike) on healthy habitual behaviors can empower them to reduce their risk of injury and chronic illness related to sedentary lifestyles.

Posture:

Gaming chairs should be ergonomically designed, with sufficient back and neck support. Gamers’ feet should be flat on the ground; otherwise, there may be an instinct to “hook” them together, leading to foot pain. Eyes should be in-line with the top of their monitor(s) to prevent unnatural neck bending. Forearms and wrists should be at (or slightly above) desk-level when using the keyboard, making any necessary adjustments to chair/desk height. This decreases wrist compression, which is a common cause of pain in gamers.

Exercise, rest and nutrition:

Physical activity must be prioritized in a gamer’s schedule. The American College of Sports Medicine recommends at least 150 minutes per week of moderate-intensity exercise for healthy adults. For prolonged sitting (e.g. gaming sessions), taking short walking breaks every hour increases blood flow throughout the body, decreasing DVT risk. Increased blood flow to the brain is also essential for optimal cognitive function.

Similarly, adequate rest and recovery are necessary for optimizing physical and mental performance. Ensure players are getting quality sleep for at least seven hours each night, encouraging the use of dark shades and ear plugs if necessary. 

Adequate nutrition also plays a vital role in maintaining a gamer’s health. Dietary guidelines recommend eating a variety of nutrient-dense foods such as fruits, vegetables, whole grains, lean proteins and legumes and limiting sugar, sodium and saturated fats. As author Michael Pollan put it: “Eat food, not too much, mostly plants.”

Adhering to this simple advice decreases the risk of chronic disease (e.g. obesity, diabetes and cardiovascular disease) and equips the gamer with the nourishment needed to make that game-winning decision or play.

Related reading:

Physicians want college eSports players to be treated like athletes

Medicine as your Second Life: What happens when the game ends?