Here's my mental model that came out of a year of reading, visiting doctors and specialists, and experimenting on my own. There are a few major pillars of wrist health. Briefly, they are: circulation, sleep, stress, knowing your limits to avoid acute injury or reinjury (within a day and over 3-5 days), gradually building to new levels of activity to avoid chronic RSI.


Acute repetitive-strain injuries (RSIs). Acute RSIs like tendinitis occur when you do substantially more with your hands than usual over a sustained period of 3-5 days. This is essentially an injury. If you rest for 2-4 days, the injury will heal. If you continue to work (typically in slowly decreasing amounts, as your pain increases), then acute RSI will convert into a chronic RSI condition.


Avoiding acute RSIs. The way to avoid giving yourself acute injuries is to keep track of how much you do, and ramp up your use of your hands just like you would increase weights at the gym--gradually and consistently. To keep track of how much I do, I use a key logger / mouse click tracker called WhatPulse. It records the number of keys and clicks I do, and allows me to "pulse" them to the WhatPulse website every night. The pulses I make are collected on the WhatPulse website, and I can later download them as a spreadsheet and make pretty graphs, etc. Now let's discuss what gradual and consistent increase in usage levels mean. When I recently started playing the game League of Legends, I started by playing one game per day. After a few days, I let myself get out of hand and I played three games. The next day, my pain was back, and I had to rest for several days. When I restarted gaming, I played one game per day for a week, and I was fine. Then, I played three or four games in a day and reinjured myself. This had happened many times in the past, and it happened again after this; ultimately, I just had to learn discipline. Eventually, I went back to one game a day, then upgraded to two games a day after a week, and to three games a day a week later. After a few more weeks, I was able to play five games a day without injury. I recommend understanding how many keys&clicks you can manage per day without suffering injury, and very gradually increasing that amount. Crucially, damage builds up over the course of several days; it doesn't simply reset when you sleep. So, for me, I can currently maintain 40,000 keys&clicks per day for about three days. On the fourth day, if I do more than 20,000 keys&clicks, I will get injured. That's the top of my mark, for where I'm at. You have to learn what it feels like when activity will cause acute RSI, and when you're okay to continue working. Learn to listen to your body, and to recognize what it means when you feel a certain way. I also recommend keeping a log of how much you do each day, any exceptional things you did (like writing a few pages, or lifting an object), and what your pain level was (and where) each night. You will be able to see patterns, and identify what levels of activity were okay, what was too much, and whether an exceptional event injured you. Also consider recording how many games (or how long) you played.


Chronic RSIs and slow healing response. Chronic RSI occurs when the rate at which you do micro damage by using your hands exceeds the rate at which your hands heal. This can occur because you're simply doing too much work for any human healing rate to deal with, but, in my experience, it's more likely that your healing rate is slower than it should be. I conjecture that the most common reason for a computer user's healing rate to be slowed is his or her lack of exercise and poor circulation, which is evidenced by cold hands when typing or playing games. Blood flow is directly proportional to the rate of healing, since blood is responsible for carrying oxygen into muscles and disposing of metabolic waste products. When limbs get injured, doctors instruct patients to first ice to eliminate swelling; then, once swelling is gone, the patient is instructed to apply heat, to increase blood flow and stimulate the healing response. Inflammation is not the bad thing that RSI sufferers are told it is. An acute injury shouldn't be iced in the first 24-72 hours, and, once a condition is chronic, ice is no longer necessary, and heat is vital. In the next three paragraphs, I'll talk about three obstacles to a fast healing response, and how to fix them.


Gaming. Personally, I started to experience severe and chronic problems with my hands when I started routinely playing online competitive games (like Starcraft II or League of Legends), and when I was stressed out about school or life. (Sometimes these triggers were compounded with my new apartment being cold, because the heating is poor.) I'll talk about games first. When you play a game for fun, and there's no investment in whether you win or lose, you typically experience fairly minimal adrenaline. However, when you play versus a human being, and especially when a match will factor into your publicly visible rank, adrenaline comes quickly and stays throughout much of the match. Your hands get icy cold, and you might even shiver despite most of your body being warm. This is because adrenaline pulls blood away from your extremities, and into the large muscles that you historically needed to run away, or fight. The lack of blood flow to your extremities makes them stiff and prone to rapid injury, and your hands can take a long time to warm up after you finish gaming. Any time that your hands spend cold is lost time in terms of the healing response. Whenever your hands are cold, micro tears in your muscle and tendon aren't being fixed.

Anecdotal evidence that warmth is vital: thumb sprains are often treated by hot wax baths that keep the hand warm for 30 minutes or more, with the intention of promoting healing; many RSI sufferers have observed improvement sleeping with their arm wrapped in warm blankets; physiotherapy seemed to help me at my physiotherapist's, but not at home, and the only difference was that my physiotherapist warmed my hands for 15 minutes before I started (and said I shouldn't bother doing that at home); studies have shown that warmth accelerates tendon repair; poor work station ergonomics cause RSI, but that too can be explained in terms of blood flow, since non-ergonomic wrist positions constrict blood flow through joints.

My solution to this issue. Whenever hands are cold, or before each game, place hands in a bucket of hot water. Five to six minutes at the start of a gaming session and a minute between games seems to be enough. I also recommend a six minute soak before bed. 109-110 degrees Fahrenheit is perfect. Note that this is 5-6 degrees Fahrenheit hotter than a typical hot tub. 112 degrees is too hot, and has resulted in tendon pain, for me. 107 is not always warm enough to give me relief. I recommend using a cooking thermometer to measure water temperature. You know how when you get in a hot tub it's too hot, but you soon adapt to it? 110 is the highest temperature that my hands quickly (within seconds) adapt to. 112 still burns my hands after 5 seconds. I credit sticking my hands in a bucket of hot water with the largest impact on my condition of anything that I did, by a WIDE margin. If you do nothing else, do this. I actually heard about this solution from someone who learned it from a physiotherapist, and used it to successfully recover from a stubborn RSI.


Sleep. Another issue that widely affects gamers and hardcore computer users is lack of sleep. Incidentally, this common issue is probably due to circadian rhythms being disrupted because a computer user's eyes are constantly bombarded with high intensity light. The effects of losing sleep are typically noticed in the one's ability to think or stay awake before they are felt in any other way, but for an RSI sufferer, lack of sleep is many times worse than for a healthy individual. During REM sleep, the healing response is greatly accelerated. In fact, the majority of your muscle (and tendon) repair is done during REM sleep. Have you ever stayed awake for more than 24 hours? The first thing I notice when I don't sleep is muscle soreness. Anyone with RSI must make 7-8 hours of sleep a mandatory minimum or they're shooting themselves in the foot (hand?). You don't enter REM sleep for the first few hours of sleep, so cutting a couple of hours of sleep might be halving your REM sleep, or worse. My rule of thumb is to assume that REM sleep happens two hours after you get to sleep, and ends two hours before you wake up. Thus, if you sleep 8 hours, you get 4 hours of regeneration. If you sleep 6 hours, you only get 2 hours of regeneration, and the amount of work you can expect to be able to do is half of your normal workload. Sleep is incredibly important. Bodybuilders emphatically state and restate this point, drilling it into gym newbies; why would it be any less necessary for the smaller muscles of your hand?

My solution to this issue: sleep 8 hours per night. No exceptions.


Stress. We’ve all heard theories that willing yourself to think that you are healthy can have a positive impact on your health. The simplest recognition of this phenomenon is the "placebo effect." People have proposed many strange mechanisms for this phenomenon, and most of them are pretty unscientific (and, hence, worthless). I propose a fairly simple mechanism. When you think positively, and convince yourself that you are well (or will be soon), you reduce your stress level. When you are stressed, there are periods of time when you think about the issues overwhelming you, and you get little bursts of adrenaline (which chills your hands). Some people get panic attacks, with similar effects. However, even when you're not actively thinking about your problems, stress affects you on a subconscious level. It makes major hormonal changes in your body (including changes to adrenaline levels), which I conjecture lead to reduced blood flow to extremities, and, in turn, their diminished healing response. Anecdotally, I've read many forum posts from sufferers of RSI conditions in which they talk about the impact of anxiety or stress on the severity of their pain. There are also non-psychological reasons to believe that you are well, or will soon be. When you think you are injured, you alter the way you use your limbs in a subtle way. Without using your limbs as you normally would, it is possible that you will never exercise them in the ways that are necessary to make a full recovery. So, what convinced me that I was well, or would be soon? Your hands can do a whole lot. They can carry babies, lift weights, sew blankets, write books, brush teeth, do construction work, and so on. Your hand isn't going to explode if you use it to push a door open, or lift yourself off of a couch. Start doing the normal, non-repetitive things that you need to do in daily life. Do NOT do repetitive work like weight lifting.

My solution to this issue: understand that you will be fine if you use your limbs for normal day-to-day activities, and then do them. Shut down any negative thoughts about relapse or the (im)possibility of your recovery, and be relentlessly positive.


Things I tried that were bad.

·        Working through the pain

·        Freezing my wrists and continuing to work (yes, people have actually suggested this)

·        Wrist exercises

o   If your pain is caused by overuse, the solution isn't to use them some more. If you think you'll put your regular activities on hold and work out your wrists until you build up your strength, then you're way off base. Any gains you make will be specific to the exercise you did (so you won't get transfer to your regular activities), and unless the gains are exercised by your regular activities, you won't maintain them. Essentially, exercises are just an extra burden on your wrists. Exercises are appropriate when you have massive atrophe. Not when you have strength plus pain.

·        Rigid wrist braces and elastic wrist compression braces

o   I believe these caused my small, supporting muscles to atrophy. Studies have also shown that compression leads to suboptimal tendon repair. Clearly, compression leads to reduced blood flow and correspondingly diminished healing.

·        Non-steroidal anti-imflammatories (NSAIDs)

o   Inflammation is not the problem. These also wreak havoc on your stomach, and there is some question about them possibly hurting tendons (causing degeneration).

·        Excessive stretching, stretching when injured, stretching when cold, squeezing or lifting things to try to dispel pain when it starts.

o   This leads to immediate injury, more often than not. At best, it delays your healing. The best response to acute and sudden pain is to just stop doing anything and watch a TV show, etc.


Things I tried that I believe didn't help.

·        Supplements: magnesium, calcium, zinc, vitamin E (regular and high dosage), multivitamins, salmon oil, omega 3, creatine (more than 6 months supplementation)

·        Various health foods: broccoli, bananas (for potassium), grapes, baked beans, nuts, sweet potatoes

·        Working out everything except for arms

o   This actually helped with circulation a bit, so I wouldn't say it didn't help at all. However, a bucket of warm water helped more, and I did do a bit of damage to my wrists each time because, for instance, I had to hold myself down with handles when I used my legs to lift 200lb.

·        Working out with weight hooks for arms

o   Weight-hooks don't help. They still pull on the wrist, which causes injury.

·        Physiotherapy

o   Every time, they heated my wrists before I began. That helped. The exercises didn't, as evidenced by the fact that the same exercises at home, without the heat, caused injury. Perhaps the exercises would have helped with heat at home, but my impression was that it wouldn't, for the reasons I stated above under "wrist exercises." Ultimately, it wasn't necessary for me to get well.

·        Tai-chi

o   The hand positions hurt the tops of my wrists.

·        Eating 3500 calories a day for 4 months to gain weight (since muscle repair requires mesenchymal stem cells from fat stores, and I was super skinny)

o   I gained 25 pounds, but it didn’t seem to help anything.

·        Eating 6 small meals per day with creatine, fruit juices and snacks to maintain an anabolic state (to avoid consuming muscle for sustenance)


Things I didn't try that I wouldn’t recommend.

·        Pain killers

o   Clearly, this will just mask your issue, allowing it to grow.

·        Homeopathy (Arnica, etc.)

o   Homeopathy is utterly destroyed by science. It does nothing. Literally. There isn't a single molecule of active ingredient in the strongest concentration of any homeopathic remedy.

·        Glucosamine and glycogen

o   Unless you also run marathons, these won't help.

·        Chondroitin

o   If you get this from bovine sources, you might randomly die in ten years of bovine spongiform encephalitis. If you get it from marine sources, there's a remote chance it might do something. My money is on "no."

·        Manganese

o   Anyone who suggests supplementing this in non-trace amounts is telling you to commit suicide.

·        Celadrin (and every other joint health supplement out there)

o   Supplements are unregulated and frequently not backed by science. Enough said.

·        Conjugated linoleic acid, ZMA (and every other bodybuilding aid without scientific evidence of its efficacy)

o   No scientific proof of efficacy. No logical reason why it should help.

·        Nitric oxide patches

o   Studies demonstrate short term benefit, but no long term benefit. (One year later, no statistically significant difference.)

·        Stem cell therapies and/or surgery

o   If you don't make a change to what you're doing in your life, whatever sequence of steps got you where you are now will get you here again, only much sooner.

·        Prolotherapy might work, but I think it is about as overkill as swatting a fly by crashing a bus into it. It seems like the only benefit of the injections is to stimulate blood flow. Just stick your hands in buckets of hot water.

Older history.
For those of you who are interested in a more detailed history of my wrist problems, the following is something I drafted before I went to see a Physiatrist. It's pretty easy to correlate what I'm saying here to the graph of my progression.