CASE 1 c Dorothy A. Sparks, MD; Lisa M. Coughlin, MD; Daniel M. Chase, MD Did too much Wii cause Department of General Surgery, Danbury Hospital, your patient’s injury? University of Vermont College of Medicine, Danbury, Conn (Dr. Sparks); Motion-controlled game consoles like Wii may be used Department of Surgery, University of Toledo Medical to play virtual sports, but the injuries associated with Center, Toledo, Ohio (Dr. Coughlin); Department of them are real. Here’s what to watch for—and a handy Surgery, Hoopeston Community Memorial Hospi- table linking specific games to particular injuries. tal, Hoopeston, Ill (Dr. Chase) [email protected] The authors reported no potential conflict of interest he release of the Wii—Nintendo’s 4th generation relevant to this article. Practice gaming console—in 2006 revolutionized the video recommendationS This article is an expansion of a game industry. By March 31, 2010, more than 70 mil- poster session presented at the T › Ask patients with repeti- lion units had been sold worldwide, earning Wii the title of 12th annual northeastern ohio tive motion injuries (RMIs) 1-3 universities college of medicine “fastest-selling game console of all time.” Department of Surgery resident whether they use interactive Today, there are several game consoles that, like Wii, al- research Day in may 2009 game consoles and, if so, how low the user not only to push buttons or move levers, but to and at the american college much time they spend playing of Preventive medicine control the game using physical movements (TABLE 1). And annual meeting in virtual sports each day. C february 2010. the devices and the many sports they simulate—once popu- › Be aware that RMIs lar primarily among adolescents—are in widespread use by associated with video people of all ages, including the young and fit, out-of-shape game use are similar to “arm chair” athletes, and elderly people in senior housing, injuries associated with the rehabilitation centers, and long-term care facilities alike.4 sports they simulate. A Not surprisingly, simulated sports play has spawned an › Advise patients to take array of repetitive motion and overuse injuries. To identify the same precautions with and treat them, ask all patients who present with musculo- virtual sports as they would skeletal injuries whether they engage in game console sports with any physical activities, including warm-up exer- activities; if so, identify the type of game and how much time cises and moderation. A they spend playing it each day. Although injuries associ- ated with specific video games are often given names like Strength of recommendation (SOR) “Wii-itis,”5 “Nintendinitis,”6 and “Playstation thumb,”7 the A Good-quality patient-oriented types of injuries caused by playing simulated sports are gen- evidence B Inconsistent or limited-quality erally the same as (or similar to) injuries sustained by those patient-oriented evidence engaging in the sport itself. C Consensus, usual practice, opinion, disease-oriented evidence, case series Video game pathology is well established In 1987, Osterman et al published the first report of a muscu- loskeletal disorder associated with electronic games—a case of volar flexor tenosynovitis (“joystick digit”) trigger finger.8 Several years later, a physician coined the term “Nintendinitis” to describe video game-related overuse syndrome6—acute 404 The Journal of family PracTice | JULY 2011 | Vol 60, no 7 In a review of self- reported Wii injuries, patellar dislocation was the fourth most common injury (hand lacerations were first, followed by periorbital hematoma and forehead lacerations/ecchymoses). tendinopathy of the extensor pollicis longus musculoskeletal injuries reported (29% tendon after prolonged play with early ver- were defined as sprains and strains and sions of the thumb-activated game control- 38% as overuse injuries) involved the use of ler.9,10 In 2002, a child using a vibrating Sony the Wii to play simulated sports.17 Overuse Playstation for up to 7 hours a day received syndrome associated with Wii was initially a diagnosis of vibratory syndrome of the called “acute Wii-itis,”5 a description of acute hand.11 A few years later, a report of “Playsta- tendinopathy of the infraspinatus.18 (Infra- tion thumb,” an overuse syndrome associ- spinatus tendinopathy is most commonly ated with later generations of game consoles, associated with games involving intense arm followed.7 activity, including Wii baseball, bowling, and Several other reports of game-related boxing (TABLE 2).5 However, Wii-itis is now injury patterns can be found in medical widely used to describe any acute inflam- journals, including pressure ulcer formation matory syndrome associated with use of this (“ulcerative Nintendinitis”),12 the “How!” sign popular game console. of central palmar blistering,13 “mouse elbow” z Wii knee, for example, refers to an acute secondary to epicondylitis,14 and other ten- patellar dislocation associated with simulat- dinopathies associated with various gaming ed bowling.19 Multiple cases of patellar injury, consoles.10,15,16 All the reports clearly describe including associated osteochondral fracture, the relationship between video game use and have been reported in association with a va- the pathology, and clinical improvement af- riety of game titles, including Raymond Rav- ter cessation of the activity. ing Rabbids and Brunswick Pro Bowling.19 In a review of self-reported Wii injuries, patellar i mage © Many manifestations of Wii-itis dislocation was the fourth most common in- An epidemiologic review of the Nation- jury (hand lacerations were first, followed by CRAIG al Electronic Injury Surveillance System periorbital hematoma [“black eye”], and fore- Kiefer (http://www.cpsc.gov/library/neiss.html) head lacerations/ecchymoses).20 found that in the Wii’s first year, 67% of the z Wii shoulder, another variant of Wii- JfPonline.com Vol 60, no 7 | JULY 2011 | The Journal of family PracTice 405 TABLE 1 Popular motion-controlled games: A partial list Type of game console Microsoft Xbox 360: Sony Playstation 3: nintendo: Wii Kinect Move Motion-control handheld remote full body handheld remote mechanism Games bundled Wii Sports Kinect adventures PS3 Sports champions with console Popular games Wii fit Kinect Sports Sports champions Wii Play Dance central Time crisis: razing Storm mario Kart your Shape: fitness evolved Killzone 3 Super Smash Bros Brawl The Biggest loser: little Big Planet 2 ultimate Workout guitar hero iii: Sorcery legends of rock Kinectimals Tendinopathy Manufacturer- ≤6 feet using ≥6 feet from device ≥6 feet from device of the recommended game wireless sensor infraspinatus, space also known as Sources: 1. nintendo (http://www.nintendo.com/consumer/wiisafety.jsp). 2. microsoft Xbox 360 (http:www.xbox.com/en-uS/ acute Wii-itis, Kinect/PrivacyandonlineSafety). 3. Sony Playstation (http://us.playstation.com/support/answer/index.htm). involves pain and weakness associated with itis, is an acute inflammation of the upper drome21 after playing Wii bowling for long active external extremity musculature after repetitive mo- periods of time. The case involved a 19-year- rotation tion. This injury is most often associated with old woman who presented with swelling over of the arm. games that require swinging of the controller, the volar wrist and had positive Tinel and such as Wii tennis or bowling. Upper extremity Phalen signs. She received conservative treat- magnetic resonance imaging (MRI) of one Wii ment with etodolac, a nightly volar splint, enthusiast revealed inflammatory swelling of cold compresses, and rest. the shoulder joint that extended to the supra- z Achilles Wii-itis refers to a partial or scapular region, corresponding to a diagnosis complete rupture of the Achilles tendon of delayed–onset muscle soreness (DOMS).9 during simulated sports activity.22 This in- z DoMS, which is often associated with jury has been reported in people using the acute injury patterns, is a well-accepted di- Wii Fit exercise pad for virtual running and agnosis among patients who play physically stretching, and is diagnosed clinically with interactive sports and, by extension, video a positive Thompson sign (failure to plantar games.17 Usually lacking frank deformity on flex the foot while compressing the gastroc- plain radiographs, DOMS is a disorder of the nemius). Complete Achilles rupture requires soft tissue that can best be visualized with surgical repair, but less severe cases can be MRI delineation of tissue planes and mus- treated conservatively, with cold compresses, culature compartments. Clinical signs and lifestyle modification, and nonsteroidal anti- symptoms of DOMS can include edema of inflammatory drugs (NSAIDs). the affected extremity, rubor, and tenderness to palpation during active range of motion. Treatment for DOMS, like all RMIs, includes Categorizing Wii-type injuries cessation of the offending activity. Game-related injuries typically fall into Another recently reported variant of Wii- 4 broad categories: tendinopathy, bursitis, itis is the acute onset of carpal tunnel syn- enthesitis, and epicondylitis. (See TABLE 2 for 406 The Journal of family PracTice | JULY 2011 | Vol 60, no 7 WII INJURY TABLE 2 Repetitive motion injuries (and possible causes)*30,36 Type of injury games with potential for injury† Possible injury sites common physical exam findings Tendinopathy guitar hero iii: legends of rock achilles tendon Pain or stiffness in the local area of the ten- don. Progression can lead to