

Ask YC: tendonitis at a startup? - lsb

I've been at a startup 7 months, and I'm feeling that my wrists are rapidly deteriorating.  How would one write code for 15 hrs/day in such a setting?
======
iamelgringo
Get religion about good ergonomics.

First a little story: my wife got carpal tunnel so bad in the 90's, she was
barely able to button a shirt for 3-4 months, and had to wear splints for
almost a whole year. She worked for a high-tech firm and had to leave the
corporate world because of her wrists. Things got a lot better, but she didn't
type for 3-4 years after that episode. She can type now for 1-2 hours a day,
tops. After that, she has pain.

Hackers are like surgeons: worthless without their hands. Your wrists and
hands are your bread and butter. Take care of them.

Get religion about ergonomics. Read up online about it. There's tons of
information, try a lot of things out and see if they help.

I use the smart glove: <http://www.imakproducts.com/products/smart_glove.htm>

Imak ergo beads:
[http://www.imakproducts.com/Products/WristCushionForKeyboard...](http://www.imakproducts.com/Products/WristCushionForKeyboard.aspx)

The MSFT natural keyboard:
[http://www.microsoft.com/hardware/mouseandkeyboard/productde...](http://www.microsoft.com/hardware/mouseandkeyboard/productdetails.aspx?pid=022)

I go back and forth between a track ball and a mouse.

I also got an ergotron monitor arm:
[http://www.ergotron.com/Products/DeskMounts/tabid/71/ctl/Pro...](http://www.ergotron.com/Products/DeskMounts/tabid/71/ctl/Product/mid/396/PRDID/1/language/en-
US/default.aspx) It's amazing how much less my neck hurts, and how much easier
it is on my eyes, because I can change the monitor's position so easily, I do
it a lot more often.

And, I couldn't quite afford an Aeron Chair, so I went to OfficeMax, and got a
knock-off:
[http://www.officemax.com/omax/catalog/sku.jsp?skuId=20952042...](http://www.officemax.com/omax/catalog/sku.jsp?skuId=20952042&searchString=)

It makes a world of difference for my back, and a better sitting posture means
that I lean on my wrists less, causing less wrist and hand pain.

~~~
mechanical_fish
Getting serious about ergonomics is an interesting combination of large up-
front expense and cheap little hacks and exercises.

Budget $2000. I'm serious about this. The things you buy will last you for
years, and $2000 will pay for itself if it saves you two weeks of sick time or
a couple of doctor visits.

You may not actually have to spend all of that, but you are going to want:

* An excellent chair ($800 range. Feel free to try the cheaper chairs... I have an Aeron but frankly have no idea if it's worth it. I bought it after using one at work for six months, and discovering it was okay. Testing chairs is difficult and expensive, so I recommend starting out in the midrange rather than spending months working your way up from the $50 OfficeMax chairs. If you find that the more expensive ones are 5% better for you, spend the money.)

The goal with chairs is adjustability. I recommend a chair with adjustable
arms, because sometimes when my shoulders get sore I move them up to brace my
elbows during rest periods.

* An excellent keyboard. MSFT natural keyboard is a great value, but I switched to the Kinesis Advantage Pro six months ago, and it kicks butt: <http://www.kinesis-ergo.com/> ). It costs something like $350. It looks like it was designed by aliens. You will feel like an idiot for the first week as you relearn all your typing and gradually remap all the keys to your favorite locations. If you don't know how to touch type... you will learn. But then you will experience the joy of feeling like you are typing while barely moving your hands.

* I concur with the Ergotron monitor arms. Being able to adjust the monitor to _exactly_ the right position is important.

* A proper keyboard drawer. You want the kind with the arm that lets you adjust the keyboard to arbitrary angles and heights, and slide it in and out. If you use the mouse, you want to be able to mount the mouse at one side. Something like the ones on this page: [http://www.ergoindemand.com/keyboard-tray-adjustable-shelf.h...](http://www.ergoindemand.com/keyboard-tray-adjustable-shelf.htm) . I would tell you the brand I use, but I picked mine out of the trash by the side of the road. (Arlington, MA -- there are real advantages of living in a startup hub!)

Then you have to hack. Once you've spent money on the raw materials,
ergonomics is a game of inches. I have one of those damned expensive Aeron
chairs, but just this year I discovered that it doesn't provide enough upper
back support, so I strapped a cushion to the top with a bungie cord :). Cost:
maybe $20, and the pain is gone. My right arm got sore using the mouse. I
discovered that if I took my mouse support off the keyboard drawer and
reattached it using a different bolt and some homemade washers, I could raise
it by four inches. And, just like that, the pain went away.

See a physical therapist. If you do nothing else, do this. The good ones are
_amazingly_ smart. Don't wear wacky gloves or wrist braces without consulting
one. It turns out that most of my own occasional wrist pain is caused by nerve
pinches in my neck, and treating the wrists is mostly a waste of time...

Oh, and of course: don't type on a laptop keyboard for more than an hour or
two every week. Laptops are ergonomically terrifying. Sorry to have to break
this one to you. :)

~~~
sarosh
First, thanks for the great advice. But, any ergonomic advice at all for
MacBook/MBP users (aside from just don't do it)? E.g. can anyone recommend a
good keyboard replacement or app or something else?

~~~
mechanical_fish
Oh, my main machine is a MacBook. The secret is to realize that laptops are
for occasional use in libraries or lectures or hotel rooms, not for real work.
It turns out that there really is a reason why pros work in real offices with
real desks instead of at a table in the local coffeeshop.

To save yourself from your Macbook, pretend it's a desktop as much as you can.
Buy an external keyboard. (I recommend the Kinesis, of course, but even a
cheapo standard keyboard is better than the one on the notebook itself.) Buy
the nifty Ergotron arm that lets you sit the laptop, open, on a tray and then
move the tray around in space until the screen is at the proper height and
distance. (<http://www.provantage.com/ergotron-45-192-194~7ERGT06R.htm> )

Now, since you're stuck at a desk anyway, buy a _real_ monitor -- I have a 20"
widescreen -- and another Ergotron arm (they have very nice 2-packs -- follow
links from here: <http://www.codinghorror.com/blog/archives/000959.html>) and
mount that on your desk, then have the laptop drive it as a second monitor.
Now you are more productive, because you have more screen space, and you also
have a real desk with a real keyboard that you can mount where it needs to be:
in your lap.

The problem with laptop keyboards isn't the keyboard, per se; it's the fact
that the thing is attached to the screen. You either have to stare down into
your lap or raise your arms almost to the level of the screen. Either of these
things can eventually cripple you. Obviously, your mileage will vary depending
on how old you are, how much you type, your physical condition, your genetic
heritage and the phase of the moon -- but, once you even start to _think_ that
you're feeling pain, you should immediately get serious about ergonomics.

I've been thinking about how to travel and still get work done. It's not an
easy problem to solve. Carrying around my Kinesis and some sort of contraption
that lets me elevate the laptop and its screen would be great. A sort of
clamp-on, foldable, lightweight, portable keyboard drawer that could attach to
the edge of a hotel desk and hold the keyboard at lap level would be _truly_
great... though perhaps rather difficult to implement.

~~~
sbraford
This is great stuff. Thank you for posting this!

I normally have a dual-screen setup powered by desktops plus a nice keyboard +
mouse.

But I'm in the process of moving abroad and will be living out of my laptop
for a little while.

You see some people at startups working straight off their laptops, day in and
out. After 1-2 days on my raw Macbook, I have no idea how they do it.

~~~
mechanical_fish
I'd strongly encourage you to rent some screens and a keyboard while you're
abroad, buy them (used, if possible) and sell them used when you leave, buy
them abroad and ship them home to yourself, ship them to your destination and
then ship them back...

Whether or not you will be able to find any desk space abroad is, of course, a
different problem.

Keyboards and monitors are now lightweight and cheap. I'm hoping to make this
fact work for me when next I need to relocate temporarily...

------
dazzawazza
Ten years ago I got pains in my hands and after various visits to my GP I was
referred to a specialist. He dutifully looked at my hands and arms and asked
lots of questions about where the pain is, what I do for a living, what
medication I'm on, do I have any family history.

He then told me I was an idiot. He didn't understand why I thought I could
type for 15 hours a day. Why I expected my tendons to put up with this kind of
punishment. I got the feeling that if he could he would have kicked me in the
nuts. He told me he could give me medication to reduce swelling but what would
the point be. The pain is there because you are pushing yourself too far! Hmm
I thought. What an idiot (with a lot of letter after his name). He told me to
stop being an idiot and come back in six months if there was any pain.

I was pretty young at the time, I went to my boss and we spoke about the
specialist. He told me I was an bloody idiot (I'm English so we're allowed to
say these kinds of things to each other btw). He said it's "..great that you
want to work for 15 hours a day but think about it. Your body is telling you
something". Then he told me something that changed my perspective on coding.
He said "It's not how much you type it's what you type". This single sentence
made me a better, healthier, more considered and sophisticated programmer.

For the last ten years I've been a better, more productive programmer and if I
ever see that specialist again I will shake his hand with my very healthy pain
free hands.

Good luck

------
pcowans
One important point is to take breaks often - get someting like Workrave and
set it to force you to stop typing for 30 second every 5 minutes and take a
longer break every hour. This doesn't really affect productivity, as you can
think about your code during the breaks, and in fact probably improves it.

I had mild tendonitis when I was writing up my PhD, and found that forcing
myself to take breaks made a huge difference.

~~~
pcowans
... and also, if you have a laptop, force yourself to only use it at a desk,
not on the couch or in bed.

------
rcoder
First, I'll second the folks who have already responded by saying that you
shouldn't be typing for 15 hours per day. _Coding_ , perhaps, but easily 1/2
or 2/3 of the time you spend programming should be spent thinking, reading
code, etc. If you're consistently banging out line after line of new code for
>12 hours per day, something is horribly wrong with your workflow, and I can't
imagine you're getting much of an opportunity to refactor and test your code
as you go.

That being said, I've found that even 8-10 hours of steady typing can be too
much for me, unless I'm using an ergonomic keyboard and good office furniture.
If you can find any model of keyboard at all that works for you, buy it. Ditto
for wrist rests, chairs, monitors, whatever. If it's expensive, make your
employer pay for it. No manager worth their salt should look askance at
spending $1-2k if it'll keep you in front of the keyboard for even an hour
longer per day.

If you're working for yourself and therefore self-imposing these ridiculous
hours and spending limits, then stop. Seriously, just stop. Think about
whether the payoff is going to be big enough to make crippling yourself for
life. Hell, if you're really sitting at a computer for 15 hours a day, you're
probably at risk of getting blood clots in your legs from lack of motion. No
startup is worth dying over, or even seriously degrading your quality of
living in the future.

------
mcxx
An addition to all the great advice: remap Caps Lock to act as Ctrl.

~~~
ptn
Or, like me, use the edge of your hand to press it :) (you know the little
bone at the joint of the pinky with the rest of the palm? That's what I use to
press the left Ctrl)

------
merrick33
I found that the new apple keyboards really helped ease my wrists pain. They
are so flat that I no longer needed a gel pad in front of my keyboard.

~~~
curi
I love them too, but because the keys take so little force to press.

------
axod
Think more, code less :) Often I find the more time you spend thinking, the
less code you need to write, because you end up with an elegant solution. Sure
sometimes you need to churn out the boring code as well... I'd say use a
laptop. I simply can't use an old style desktop keyboard - key travel is way
too far.

------
shimon
The most important thing for your wrists is to keep the bones in your palm
relatively straight with respect to your forearm. If you bend your wrists up,
bad things can happen.

I work about 8h per day while walking slowly on a treadmill:
[http://rura.org/blog/2007/11/14/the-treadmill-desk-
exercise-...](http://rura.org/blog/2007/11/14/the-treadmill-desk-exercise-for-
the-sake-of-hacking/) In that configuration, I need a keyboard tray that's
angled away from me at a somewhat sharp angle, so I can keep my wrists
straight and have my elbows open at about a 120 degree angle.

~~~
icky
> The most important thing for your wrists is to keep the bones in your palm
> relatively straight with respect to your forearm. If you bend your wrists
> up, bad things can happen.

Indeed: if you have to reach up to type, you are destroying your wrists.

With a laptop, you are stuck in the unenviable position of having to choose
between wrist pains and neck cramps, since the keyboard and monitor are
separate.

For a laptop:

Get a wireless keyboard (a wired one will get annoying if you have spinny
chairs or accidentally yank on the cord), with a built-in trackpad, and keep
it in your lap to type.

Then get either an external display, or raise your laptop's existing display
(a stack of phone books should do it), so that your eye level is about 1/3
down the screen.

------
watmough
Answer: You can't.

I have RSI flare up when I'm working particularly hard (I'm a business
consultant), and it's not fun. Aside from taking NSAIDs, the only real cure
that I've found is to stop typing and mousing so much. And working hard to me,
means >10 hours a day, plus at least one weekend day.

If I slack off a bit, then the RSI goes away until the next timecrunch, burn,
death-march, etc. ;-)

I also have a Logitech MarbleMan trackbar, and that does help, though after a
mouse, the trackball is a tad annoying to use, especially one without a
scrollwheel.

------
wallflower
I remember having temporary pain from working alot and it would go away after
a couple days...

The bad thing - at some point, it becames residual - no amount of rest (short
of 6-12 months of keyboard abstinence) will let you recover. You have to start
proactively manage - You've broken the proverbial straw on the camel's back.

That was years ago, I have a much-less painful, residual level of aching (2.5
on a scale of 1 to 10).

Nowadays, I manage my work, with occasional flare ups (4/10). My advice is to
get WorkPace restbreak software to force you take breaks. Consider using an
burst-proof exercise ball chair (forces you to work your abs)
<http://www.fitter1.com/Catalog/Items/FBCJ.aspx>

Take Yoga classes, swimming (great full-body exercise, zero-impact). Alexander
technique is good for gaining body awareness as well. If you slouch your head
is like a bowling-ball weight that causes a domino-effect of strain on your
entire backbone/spine.

The good thing, if there is a good thing about RSI symptoms, is that you may
start to realize that you may not be able to be a programmer for as long as
you wanted and you start to diversify and you will _not_ take your programming
job for granted. And you become a much more efficient programmer..

------
herdrick
To prevent this kind of thing in the first place: Stop typing at regular
intervals, stand up, and run your fingers and wrists through a range of
flexion and extension motions while moving your arms around, especially over
your head and back down again. This will get more blood flowing in the area,
which helps. Strength training of your wrists, shoulders, abs and back helps.
Wear wrist braces _at night_. People often push their wrists into strange
positions while asleep - this will prevent that. But _do not_ wear them any
other time - they will cause muscle atrophy which makes things worse.

You've waited a while though, so you'll probably need to stop typing entirely
for a month to let the inflammation go away first.

JWZ is worth reading on this. <http://www.jwz.org/gruntle/wrists.html>

My final advice: try occupational therapists and physical therapists.
Physicians aren't as good about knowing specifically what to change about your
behavior and how to get you to do it. The better occupational and physical
therapists think about these issues constantly.

------
andrewf
If you often bang keys for 20 seconds, then sit still thinking for 40 seconds,
try adjusting that split to 30+30. You're typing slower but you're not working
slower.

Variety works well for me. I had a bad pain that was triggered by depressing
the left mouse button. I now alternate my mouse between hands on a roughly
weekly basis. After the first few days mousing left handed, it was no longer
slowing me down.

Also, I find alternating seat height, keyboard type and position, screen
height, etc eases the general back and neck pains that can come with sitting
in the same position for too long. Whether 3+3+3+3 hours in varied positions
is better than 12 hours in the same, "optimal" position is probably something
physiotherapists would never agree on.

On medication: you don't want to use painkillers to enable your pushing too
hard. On the other hand, my understanding is that inflammation is a bit of a
vicious circle (inflamed tissues are more easily further irritated), so anti-
inflammatories are your friends. Topical medication may be more or less
effective than pills, and are less likely to screw up your stomach.

------
snowmaker
Anyone who thinks they have RSI should read Dr. Sarno's theories about RSI:
<http://podolsky.everybody.org/rsi/>

All is not as it seems with RSI, and you should trust what the scientific
research shows, not what your physical therapist with a PTA degree tells you.

------
chandrab
Better take care of this asap. I've got medial epicondylitis, better known as
golfer's elbow from typing to much. I've tried everything to get rid of it
including 4 months of PT, but it always comes back. It sucks. I'll try
anything at this point.

------
tipjoy
At an old job in 2003, my office mate quit and left these amazing hand rests
which I began to use. I loved them so much that when they broke in 2006 I
actually super glued them back together. At that time I couldn't find anyone
selling them on the web. Now, they've broken again and it looks like I can get
them here: <http://www.ausconn.com/> \- see the "Comfort glide" area - third
picture from the top left (I know, amazing website). Apparently they're made
in Australia. Seriously, these things are amazing.

------
icey
I've been plagued with tendonitis on and off since I started typing like 20
years ago. The number one thing that I've found has helped is keeping track of
my wrist alignment. Make sure your wrists are on a straight plane.

The easy way to describe it is that your wrists should be simliar to their
natural resting position while you type.

A common problem that people have is that they use their wrist and elbow
muscles while they type, and it puts a ton of stress on the joints and
tendons.

------
boredguy8
Colemak layout works wonders, and for me was much more pleasant than Dvorak
(plus, the transition is easier).

<http://colemak.com/>

~~~
eru
How informed is your impression of Dvorak? I see that Colemak can be easier to
learn for querty-typists, but the other points in the FAQ do not seem that
vital.

(FAQ:
[http://colemak.com/FAQ#What.27s_wrong_with_the_Dvorak_layout...](http://colemak.com/FAQ#What.27s_wrong_with_the_Dvorak_layout.3F))

P.S. I do not want to start a flame war. Pretty much everything is better than
querty.

~~~
boredguy8
I spent about 4 weeks working on the transition to Dvorak, and it never
'clicked' for me, and at the end I was in the 40s for my WPM touch-typing
Dvorak whereas I'm about 85 on QWERTY. After 2 weeks in Colemak, I'm at 40 WPM
and growing.

If "learning curve" is stopping you from switching keyboard layouts (as it was
me), don't let it: Colemak decreases that transition time to bearable levels.

~~~
eru
I switched to Dvorak some years ago. Because the keys on the keyboard did not
match what you got when you pressed them - Dvorak forced me to touch type -
which I hadn't been able to do on querty (or rather quertz) for lack of
pressure.

Now I am much better at querty and Dvorak. You do not unlearn the old layout.
In fact I find that I can alternate between both layouts as fast as I can tell
the computer to switch. (I assigned the windows-key for switching.)

------
aaroniba
I am a long-time kinesis user because I find the kinesis i the best
combination of speed and comfort. But once I head really crippling RSI, I
switched to the safetype keyboard (www.safetype.com) for a few weeks, and
found it even more comfortable. Eventually I switched back to the kinesis
because of the speed and accuracy, but the safetype is worth a try if you have
really bad pains.

www.safetype.com

------
kingnothing
I love all of Microsoft's ergonomic keyboards and highly recommend one. They
lead to your hands being in a more natural position than on a straight
keyboard. Nowadays, I can't type for more than maybe an hour on a regular
keyboard before my wrists start to hurt, but I have no problems on ergonomic
ones.

------
dawnerd
I've found that resting my arms at the same height as the keyboard really
helps.

------
daniel-cussen
I didn't know this could be as big of a deal as it is. Now I know; thanks isb.

------
chris_l
Whenever this question comes up I recommend the Alexander Technique. That
worked for me, reply with email for more info.

~~~
musiciangames
This from the ACT RSI group (Australia):

Some treatments were moderately or very successful for most who tried them,
with very little or no adverse effect. These were:

    
    
        * Bowen Therapy
        * Alexander Technique
        * Tai Chi
        * Self Hypnosis
    

Treatments with adverse effects on more than 20% of those who tried them
included:

    
    
        * Swimming
        * Carpal tunnel surgery
        * Local anaesthetic injections
        * Traction (the standout villain!)
        * Stretches from a physio
        * Cortisone injections
    

<http://www.rsi.org.au/treatments.html>

~~~
musiciangames
There is now some good science to show that Alexander Technique is effective,
at least for lower back pain:

<http://alexandertechniquenorthside.ie/back-pain.html>

------
__
Don't use Emacs.

~~~
mechanical_fish
Yes and no. The default Emacs setup on a standard keyboard can be a problem --
the pinkies, how they ache! -- but I find that using the mouse is even worse,
so if my emacs alternative involves mousing I have an even bigger problem.

You have not lived until you've used Emacs with the Kinesis keyboard. You can
remap any key to any other key instantly _within the keyboard itself_ ,
without mucking around in your OS. And there are bunches of thumb keys. All
those wacky control and meta keys now live, in mirrored pairs, under my
thumbs, and the Caps Lock function has been moved to a random, faraway key, to
be replaced by my own personal prefix key that I can use to trigger stuff like
snippets and abbreviations.

~~~
curi
If you need to hit modifier keys a lot on a normal keyboard, move your whole
hand and press them with your index and middle fingers together, instead of
using your pinky.

~~~
eru
Moving my whole hand is slow..

------
axiom
<http://www.datahand.com/>

------
jamescoops
Do yoga and pilates and stretching exercises every day

~~~
ptn
Maybe in-between coding sessions...

Give yourself a little massage every now and then to relax the accumulated
tension.

------
curi
1) ergonomics. for example, if you have a laptop, keep in mind you should put
the screen at the right height (ie, on some books or something) and then use
external keyboard+mouse)

2) ergonomics. type with straight wrists. if you rest your palms on the table
by the keyboard and bend your wrists up, while typing, that will hurt you

3) attitude and mood are important. when i was really scared of the pain, and
obsessing about it, it made it a lot worse. at some point i relaxed and it
felt a lot better. obviously that won't work in all cases, and you still have
to be careful, but if you're scared every little nerve impulse means you're
too crippled to work and your life is ruined, you can imagine more pain than
you have.

4) form habits. some ppl play with their hair while thinking, or shake their
leg, or bite their tongue. when you're thinking about how to write the next
piece of code, you want to be unconsciously stretching. make it something you
do automatically when you aren't paying attention to what you're physically
doing.

5) i don't like chair arm rests. partly they are too far apart, and they have
to be unless your chair width really hugs your body. i use a pillow in my lap
(and supported on the ends by the arm rests) at all times. it's from an old
couch and not too hard or soft. it gives me somewhere comfortable to rest my
arms whenever i'm not typing, as well. your mileage may vary, but feel free to
improvise if it's comfortable.

~~~
gills
Second the arm rest bit and stretching habits.

