Her wrists were in agony. Julia Bright had only been playing Overwatch online for two hours, a fraction of her usual daily investment in the game, but she could take no more. Desperate to soothe her hands and forearms, she plunged them deep into a bucket of ice water. The freezing liquid helped, a bit. But after a few minutes, that too induced its own kind of pain.
Bright was used to playing around eight hours of Overwatch, a wildly popular team-based first-person shooter (FPS), every day. Lately, though, she had been forced to drastically curtail her practice sessions or “scrims”. It was her right hand that hurt the most – the one she used to hold her mouse. Bright had developed a habit of grasping the curved, jet-black device with a claw-like grip that tightened sharply during moments of intense play.
She was 20 years old, living with her parents in North Carolina on a gap year, and gunning for a career as a professional esports star. Those who make it in the Overwatch League can net six-figure salaries and share prize pools worth up to $5 million. On paper, her chances were decent. She had a winning record and, by then, years of experience pwning would-be challengers online in various FPS games. When she first got into gaming as a teenager, Bright quickly recognised a competitive spirit within herself. “It could feel like a fire.” she says. “I always wanted to win.”
But now, injured and relegated to the position of substitute on her team, everything was falling apart. She lay awake at night worrying, wondering whether the awful pain would plague her for life. Things had started to go awry early last year, prior to the second North American open season in Overwatch, in which highly ranked but non-pro players compete with one another online. For many, it’s a major chance to prove their worth. Scouts and analysts for pro teams watch the open season closely, so performing well can be the first step towards launching a full-blown Overwatch career. But while she waited for the season to begin, Bright found herself distracted by another game.
“The way that I fucked up,” she remembers, “was I did not take care of my wrists while I was grinding Apex Legends.” In the past, Bright says she’d made an effort to do hand stretches and take regular breaks. But Apex Legends – a then-newly released FPS game where players form small teams to battle others online – engrossed her to such an extent that she neglected to do this for around two months.
She noticed that her worsening pain was accompanied by a strange, walnut-shaped swelling on her wrist. Her doctor referred her to a hand specialist but getting a satisfactory diagnosis took months. Initially, the specialist suggested Bright’s injury was tendinitis, an inflamed tendon, something that likely just needed rest. But rest didn’t help. Neither did physiotherapy or steroid injections. Nothing seemed to work.
An MRI scan in October revealed the cause of pain: a torn ligament and displaced tendon. Her doctor agreed it was most likely due to overuse from video gaming. The good news was that she now had the option of a surgery. “I cried my eyes out to my mom that night,” Bright recalls. Having feared that she might be stuck with intense wrist pain for life, now, at least, she had hope.
After the operation, Bright wore a cast on her wrist for about six weeks and then a brace for another six after that. A few months of physiotherapy and rest followed. Bright still plays video games – the FPS Valorant is her pursuit of choice at the moment – but only for short, 40-minute sessions at a time. She’s had to accept that her hopes of becoming a pro gamer are over for now. Her wrist, while much better, is still only about 80 per cent recovered, she says, and in order to regain her competitive edge, she’d have to grind so much that she could jeopardise her health once again. “I was getting so close on my last team,” she says. “I was the best I had ever been.”
Professional gaming is now a billion-dollar industry with an estimated global audience of around 500 million people
Jeff Vinnick/Getty Images
Lindsey Migliore is a doctor who understands the ins and outs of gaming. She has been playing video games since she was six years old – all the way through school, college and into her career in medicine. A few years ago, she started playing the hugely popular battle royale title Fortnite regularly with a group of seven friends, all of whom were doctors as well. When they started experiencing hand pain around the same time, Migliore, a physical medicine and rehabilitation doctor, realised that it was likely connected to their intense gaming sessions.
Many medical professionals are still waking up to the fact that esports competitors are at risk from serious health issues. But there is little official guidance on esports medicine and doctors don’t often get a chance to assess pro gamers before their injuries and ailments ramp up. Migliore, who styles herself as ‘GamerDoc’, says her own experiences have inspired her to try to change this.
For two years now, she has worked directly with esports athletes – as a medical professional advising school-age competitors and also as a consultant for pro teams. But people get in touch with her online all the time, too, she says. She gets direct messages on Twitter two or three times a day, on average, from someone worried about a symptom potentially linked to gaming. Migliore, who doesn’t provide medical advice over Twitter, says she does her best to point people in the direction of useful resources or professionals who can help them.
She knows how bad things can get. A handful of gamers Migliore has worked with directly have been left with constant pain. “Over time, you get these chronic micro traumas, these tears,” she explains, describing what can happen to human tissues after years of button-mashing. Then, a slight but sudden shock to that musculature, anything from pushing a heavy bag into a car boot or swinging a bowling ball can cause a bigger injury in the worn out tissue.
And while she hasn’t seen a displaced tendon like the one suffered by Bright among any of her own patients yet, she acknowledges that it’s something that could happen to a gamer. Esports athletes, she says, perform up to 600 actions per minute with their fingers while playing some games. But human hands evolved for climbing trees.
It’s an increasingly common problem for aspiring gamers. Esports is booming. Professional gaming is now a billion-dollar industry with an estimated global audience of around 500 million people, and tournaments where prize pools stretch to many millions of dollars. In some countries, including the UK, it’s even possible to join an esports programme at school or get an esports scholarship to university.
For those pushing for greatness, the toll on their bodies can be high. Esports insiders, including players and coaches, are increasingly worried about the pressures that competitive gamers face. Player health varies widely, with issues ranging from hand, neck and back pain that sometimes requires surgery, to poor nutrition, bouts of insomnia and mental health issues including anxiety, depression and burnout.
In June, 23-year-old League of Legends champion Jian ‘Uzi’ Zihao – who is considered China’s most famous esports star, having racked up more kills during tournaments than anyone else in the world – shocked many in esports when he announced that he was retiring because his mental and physical health had deteriorated so much.
Help is available – but only for the few who become esports superstars. In some cases medical professionals advise top players directly, helping them to, for example, stay in good physical shape and improve their diets or quality of sleep. Some teams claim to be leading the way by providing esports athletes with access to sports psychologists and meticulously designed regimens incorporating exercise, nutrition, sleep and breaks away from gaming. It’s billed as a win-win: player health is boosted, which in turn means they are likely to do better in their matches, too.
But this is my no means the norm. Access to support like this can depend on a player’s position in their gaming league of choice, what country they live in or the particular team to which they happen to be signed. Not all competitive gamers have the luxury of coaches who monitor their wellbeing on a daily basis. Especially those who aren’t yet pro.
Since video gamers push their bodies in a very specialised direction, they need to maintain their physique, stay hydrated and eat well, among other things, says Migliore. That helps to prevent injuries and long-term problems such as nerve damage. And yet there is evidence that many esports athletes aren’t aware of how important it is to keep a balanced lifestyle.
“They view themselves for the most part as perfectly healthy,” says Hallie Zwibel, director of the New York Institute of Technology’s (NYIT) Center for Sports Medicine and an expert in esports medicine. One survey of more than 1,000 esports players in Germany found that their sleep patterns and fruit and vegetable intake were poor – despite respondents reporting that they thought they were in good health.
Zwibel has worked with NYIT’s own esports teams and studied the physique of gamers competing at the university level. “If you dig a little bit deeper, and not too deep at all, you find there are significant issues that really do need to be addressed,” he says, referring to muscular pain, eye strain and dietary imbalances. Such problems, left untreated, can go on to trigger early retirements from the sport.
Zwibel and his colleagues have investigated what can go wrong for esports gamers when they adopt problematic behaviours and routines. Their survey of 65 university-age esports players found that most reported some kind of muscular pain or fatigue – but just two per cent had sought medical advice about it. Another, smaller survey of a similar cohort found that esports players had unusually large amounts of body fat. Despite looking relatively trim, because these individuals had such sedentary lives and lower muscle mass, technically they were obese.
That this is the underlying picture for many esports athletes is worrying to physicians like Migliore. And dealing with physical complaints only increases the stress of having to perform as an athlete. “They are getting burned out and they are dealing with both physical and mental injuries that are untreated,” she says.
A common refrain is that pro gamers’ hand-eye reaction times unavoidably wane in their early to mid-twenties, which means they are bound to peak competitively around this age. Migliore rejects this emphatically. “That’s crap. We know that’s crap,” she says, referring to basketball stars like LeBron James and Michael Jordan who have played at the highest level of their sport well into their late twenties and beyond. “Did we miss the LeBron James of Rocket League because he had a wrist injury when he was 20 and had to retire?”
Players during the final of the Solo competition at the 2019 Fortnite World Cup in July 2019 at the Arthur Ashe Stadium in New York City
JOHANNES EISELE/AFP via Getty Images
When Jayke Paulsen stepped off the plane in Sydney for the first time, it all became real. His flight had been paid for by Riot Games, the firm that makes League of Legends, a popular real-time strategy game. Paulsen was about to turn 20 and had never been to the city before. Over the coming months he’d be flown back and forth multiple times to play in-person with teammates who had only collaborated with him online before. The next year, 2017, he moved to a gaming house in Sydney full-time, where he, his coach and co-competitors all lived and practised together regularly. He’d made it to the elite ranks of esports professionals.
But over the years, Paulsen noticed how some players he knew didn’t seem to take care of their health. Some had wrist injuries or concerning symptoms like tingling and numbness in their arms after long periods of play, he says, but they carried on doing marathon sessions anyway.
Ultimately, though, what put Paulsen off pro gaming wasn’t physical ailments, which he didn’t experience himself, but the sheer mental strain of competing. Sometimes a run of losses hit hard. “When you are doing really poorly, you start to question everything around you,” he says. He found that going to the gym helped, but he still experienced bouts of disrupted sleep and intense stress immediately before key matches.
He’s not alone in this. After a decade of playing and commenting on the game, League of Legends pundit Zack ‘Rusty’ Pye, who is now 27, also knows how the pressures of esports can ignite feelings of self-doubt and anxiety. When he first became a commentator, he was asked to analyse teams and predict how they might fare during major competitions. The vitriol he received on social media over this shocked him. “They were saying things like, ‘kill yourself’. All I did was predict a team and give a sound reasoning.”
Unlike in any other sport, esports and social media are inexorably intertwined. As a result players and others in the industry can feel the heat of online toxicity perhaps even more acutely than their counterparts in traditional sports. Pye remembers interacting with players on the receiving end of online abuse two years ago, while living in Shanghai. Hearing their stories and trying to help them cope affected him so badly that Pye “became a hermit” and didn’t leave his apartment for days on end. “It utterly broke me a couple of times in that year,” he says.
The very nature of esports makes it difficult to insulate oneself. Drake Porter, a former competitive Starcraft and League of Legends player who now has a career as a coach, recalls becoming distanced from his peers because of the path he decided to pursue as an adolescent. “I struggled with depression all the way through middle school and high school, just feeling lost and separated from kids in my area and my age,” he says.
While he says he does not regret his decision to get involved in esports at all, he argues that organisations that sign up players and coaches vary significantly in how well they help teammates cope with mental health concerns. Underlying, undiagnosed anxiety and depression can be exacerbated by the intense environment. “Those problems are either solved in esports if they’re with a good organisation,” says Porter. “Or they’re made substantially worse with esports if they’re with a bad organisation.”
Mental strain can end up being the last straw. Last year, Paulsen decided to quit, turning his back on a potentially lucrative career doing something he loved. Esports just wasn’t worth the negative impact he found it was having on him: “I wasn’t so desperate to stay there that I would have sacrificed my mental health to make it work.”
Fans at the International 2019 Dota 2 World Championships in Shanghai, China in August 2019
Hu Chengwei/Getty Images
Fabian Broich never thought he’d have anything to do with esports. As a professional football goalkeeper, he’d played for teams in Germany, Iceland and the USA. In 2018, he joined the esports division of German football club Schalke in Berlin as a sports psychologist and realised that with a carefully designed fitness schedule and monitoring of sleep, hydration and nutrition, he could help the players boost their performance. “I think we have to change everything,” he told the manager at the time.
Broich knew from personal experience that half an athlete’s battle is off the field. As a footballer, he had often felt that others on the pitch possessed more natural talent than him – but he made up for this by carefully managing his sleep and nutrition in order to perform at his best when required. He even composed raps in German as a technique to help him achieve the right mindset. Over time, he noticed that he conceded fewer goals.
In November last year, he joined Excel Esports, a UK-based organisation with League of Legends and World of Warcraft teams. When he arrived as head of performance, he instituted new schedules encompassing physical exercise, breaks and time for the players to talk about how things are going one-on-one.
Meals are carefully planned with nutrition in mind, and snacks are limited to healthy options like nuts, berries and dark chocolate. Players also have plenty of time to recuperate by meditating, doing yoga or reading. Since the team spends so much time indoors, they’re given vitamin D and other nutrient supplements, including calcium and magnesium, both of which can improve sleep.
Sleep is of particular interest to Broich, who eagerly monitors the nightly slumber of every teammate. They all have Oura rings, which they wear in bed and which use vital sign measurements to quantify things like deep sleep – when the body releases growth hormones and repairs tissues. Broich can see the latest results for each of his players at a glance – data he also shares with them regularly. As a result of his work, the team became so interested in improving their sleep scores that they started competing with one another over who had the best night’s kip.
“You’re talking to maybe the most healthy team in Europe right now,” he says. Marc ‘Caedrel’ Robert, a League of Legends pro currently under his wing, agrees. Robert doesn’t play for 12 hours straight like some competitors might. Seven to eight hours a day with plenty of time out scattered among that is enough. Before he joined Excel, he admits, he wasn’t so disciplined. “My whole regime was just wake up, play, grind, try to improve, go to bed,” he recalls. “There was no life, my life was the game.”
Now he sees things the other way round – gaming is part of his life, not the only thing that matters. And winning a match is no longer his only source of happiness, he adds. Broich’s philosophy is that esports players have many of the same bodily needs that traditional athletes have. He calls them the “pillars of performance”: sleep, nutrition, mental health and physical activity. But there are unique hurdles to achieving this in esports, he admits. For one thing, exhaustion is harder to detect when your sport necessitates sitting down for long periods of time. “At one point as traditional athletes, your body is done, your muscles are done, you can’t actually perform any more,” Broich says. “Whereas, for an esports player, unfortunately the brain just keeps going.”
Robert is by no means impervious to the pressures of competitive esports. He knows the feeling of hopelessness after a crushing loss, he says. And in the past he’s endured repetitive strain injury in his arm. But the balance he feels he’s now struck, with Broich’s help, suggests esports doesn’t have to destroy you. “I feel so different. I feel more alive,” says Robert.
But for amateur players like Bright, this kind of support network remains a distant dream. “It should start in the schools,” Broich says. That might sound far-fetched, but esports is increasingly becoming a part of school life for pupils in some countries. Dozens of schools in Denmark, for instance, now offer pupils classrooms kitted out with PCs where they can game for hours on end. Some even have “elite” programmes where esports coaches drill pupils in competitive gameplay – an effort to boost their chances of pursuing esports as a career.
Anne Fiskaali, a PhD student in psychology at Aarhus University, has been studying the rise of esports in schools and youth clubs in Denmark. She says some students respond extremely well to this. After all, it might be the first time in their lives that an adult acknowledges and encourages their interest in gaming. But, from her observations so far, the quality of advice available to students in terms of wellbeing varies from institution to institution – as does the amount of physical exercise players are expected to do. There’s no standard yet. “The students that want to be esports players,” says Fiskaali. “They need to find a way to game in a way that doesn’t lead to burnout.”
For some esports players, though, it’s already too late. Early retirement and life-long pain are amongst the risks of participating in an arena where the conventions and rules are still being developed – and where we’re still learning about the limits of body and mind. “Esports is very young,” says Bright. She draws a parallel with American football – which she used to play at school, and the old black-and-white photographs of competitors back in the 1930s. Back then, players wore little leather caps and hardly any other protective gear. Today, there’s a lot more padding and a public debate as to what sort of protection and rules of play are safest.
In esports, conversely, it still feels as though there’s a “silent race” afoot, she argues – to be the player who practises the most. And that can take a terrible toll. In the future, she and mentors like Broich and Migliore hope that it will become normal for players to adopt a healthy approach to training and competing. Better access to therapy and other forms of support could also reduce the prevalence of burnout, depression and anxiety.
But it will take an industry-wide movement to achieve it. But, for that to happen, gamers themselves have to recognise that their sport could, potentially, hurt them. It’s partly up to them to take care of the equipment they use to compete – their hands, their eyes, their body and their mind. “I always try to say to gamers, ‘listen to your body’,” Bright says. “You will regret it if you don’t.”
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