There’s a serious concern for esports players where physical injuries can overshadow their careersleading to premature career ends and serious health concerns for many players.

Recognizing this critical gap, Matthew Hwu, a Doctor of Physical Therapy, and a lifelong gamer, founded 1HP, an initiative dedicated to transforming health and wellness in the gaming and esports community. We look at the inspiration behind 1HP, and Matthew’s vision for the future of gaming.

As a Doctor of physical therapy, what inspired you to focus on esports and gaming?

Gaming has always been a large part of my life. I have always played or competed in various games growing up (CS 1.6, CS: GO, Overwatch, Fortnite) and even while I was in my doctorate program for Physical Therapy I was competing. Throughout my time in my program, I had noticed the increased frequency of stories in which players would have to retire or receive surgical interventions as a result of their lifestyle in esports.

I thought this was unusual given my understanding of the physical stressors and biomechanics. It however completely made sense as I began to dive deeper in my research into the space realizing there was minimal to no health support structures provided to these players.

Once I realized this, I knew I could combine my passion of gaming and helping people stay healthy to help build a better health & wellness infrastructure in the gaming and esports industry. This is when I started 1HP and it has since been 8 years working with some of the best players and organizations (100T, TL, Shopify, G2, NIP, FLY, etc.) in the world to help players achieve more and perform at their best.

I wanted to make sure that injuries and physical health was never going to be something holding gamers and esports athletes back from being able to participate or play in competition. My mission has and will always be to help gamers play more and hurt less.

What are the most common health issues you encounter among esports athletes and gamers? How can they be prevented or managed?

Not carpal tunnel syndrome. I want to start by making a PSA that it is almost never carpal tunnel syndrome. In the past 8 years we have treated over 2500 cases of wrist pain and there has only been one true case of MILD carpal tunnel syndrome.

It is almost always an issue involving the tendons of the wrist and hand. This is one of the largest myths in not only the gaming space but in the larger medical community. While I won’t get into too much depth as to why this occurs, I will provide broad strokes.

1. Musculoskeletal education is limited for primary-care providers (1st-line providers). In some research it shows it re-presents as little as 2% of their education.
2. Inefficient healthcare system - physicians have limited amount of time to evaluate and appropriately determine diagnoses (only about 5-10 minutes).
3. SEO perpetuating misconception - individuals look up carpal tunnel syndrome after being diagnosed which creates SEO optimized articles perpetuating the belief CTS is a leading pathology.

In our experience there are three major factors which lead to these types of injuries:

1. Posture / Ergonomics - 20% How you setup has an impact on what muscles are utilized and their time to fatigue due to poor length tension relationships.
2. Physical conditioning - 40% Your tissue capacity. How much your muscles and tendons can handle before they get irritated. Muscle endurance is the main way we build the conditioning of our muscles which is why exercise is such an important part of maintaining great physical health.
3. Lifestyle and Habits - 40% How our schedule is setup around gaming and our behaviours pre / during / post gaming. If we play for 24 hrs straight, we are creating consistent load at our muscles not allowing for any potential recovery.

By taking breaks to stretch, warming up between games, and committing to consistent exercise, nutrition, and sleep habits we can optimize recovery and adaptations.

To better prevent or manage injuries it means we should look to address these three major contributors.

1. Posture & Ergonomics - Look to improve your setup where possible but realize it is only a smaller part of your physical health. you can have small postural and ergonomic issues without any major problem provided you take care of your lifestyle and physical conditioning. Most typically we recommend a change when the postures are on the extreme end.
2. Physical Conditioning - EXERCISE IS KING. Motion is lotion. Utilize some of the routines we have listed in the OP to build a pregame warmup, between-game stretching, and post-game recovery. Then look to find a movement discipline you are interested and passionate about. I would recommend the "routines to fix pain" playlist on our YouTube which has 33 routines for every major body region and the 7 science wrist exercises as an initial start.
3. Stretch between games, warm-up before your game, take breaks consistent with the duration of your session (3 hr session: 30 min break, 4 hr session: 40min break etc.).

How do injury patterns in esports athletes compare to those in traditional sports, and what does this say about the physical demands of each?

This is a great question - I want to first start by sharing our definition of esports.

Esports is a static, endurance sport which challenges our executive functions in a virtual environment.

Comparing esports to traditional sports, esports are more static (little to no movement within small ranges of motion) than dynamic (a lot of moving bodies and at high velocities and power with the body moving through wide ranges of motion). And when we think about it, traditional sports have a physical game at its foundation whereas esports have a virtual game at its foundation, (not to say that the repetitive movements at your shoulder and wrists, and fingers aren’t physical).

The physical component to esports which as I mentioned earlier, is essentially a lot of small movements at the wrists, hands and sometimes shoulders (that could change with VR in the future).

Traditional sports can be unpredictable in nature when it comes to injuries. There are so many moving bodies at once in the team sports that are out there, and because of this it creates a lot of opportunities for injuries all over the body. And of course, depending on the sport, some body parts are injured more frequently than others.

Esports on the other hand is very predictable when it comes to injuries. It’s essentially what many of us do all day at hunched over in front of a computer at work, but to the extreme extent. Repetitive Strain in the name of the game. Millions of “actions” or little movements of the wrist/hand/forearm are performed throughout the day that consistently load the muscles and tendons that we use when we binge or play consecutive competitive matches.

A lot of players who have come back from an injury rarely achieve their previous form (mostly because they use the absence of pain as a metric for being better). It’s not just about masking the pain with some tape (while it can be helpful) – the long-term solution is more than that.

How does public perception of esports athletes' health and fitness needs compare to that of traditional sports athletes, and how does this affect support for their health and wellness?

Esports athletes continue to be seen as a population that doesn’t require the support of health and fitness professionals. While we have seen some progress on this front, recent research published in 2023 on the attitudes of athletic trainers (ATCs) towards esports showed many professionals don't see esports as an area that merits significant support.

Based on the work we've done over the past 8 years, we know this population has physical demands and risks comparable to traditional athletes, which can lead to health issues. This means regardless of whether or not one believes esports is considered a “sport”,  gamers require support to address these health issues.

This is why we started the Esports Health & Performance Institute which providers these healthcare and performance professionals with standardized education and tools to best support the community.

Where do you see the future of health and wellness in the gaming and esports industry heading?

We are already seeing changes at multiple levels in the landscape of health & wellness in gaming. The industry started with a heavy focus on the professional scene without an appropriate developmental or talent pipeline. This is a contributor to many of the issues we have seen regarding the health and wellness of the players and teams we have worked with.

Previously, esports athletes were expected to undergo the growth of a high school, collegiate, and professional athlete all in the span of 3-6 months. They had to learn how to interact with teammates, a professional organization, self-care, professional balance, work with coaches, manage PR & media, financial literacy, and so much more, all in this short amount of time. This is completely unsustainable and led to so many physical and mental health issues early in the development of the industry.

Now, there are consistent developmental structures at the middle school to collegiate level which are continuing to grow to provide these athletes with education earlier on about how to better manage their own health & wellness.

This developmental pipeline is crucial globally to ensure players are better equipped with the habits and understanding of how they can better pursue a career in gaming without sacrificing their health. We hope to continue supporting the growth of this pipeline.