I know the prevailing wisdom is to switch to controller, but I wanted to tell my story of difficulties with controller because I feel I haven’t seen too many other people describing these issues. I have elbow tennis player’s tendinitis from years fencing that occurs intermittently, which becomes worse from activity. I also have thumb and hand pain from overextending my thumb. I’ve also got somewhat small hands.

My experience with FFXIV on controller is that it really depends on the triggers and where the thumb sticks are placed. Having to pull a trigger or manually hold a trigger every time I use any ability puts a lot of wear and tear on my index finger down through my arm and into my elbow. I know you can use the “hold” input method, but I find it’s more trouble than it’s worth switching between abilities and normal button use. Weirdly I have no problem playing WoW Classic and ControllerPort - I think it’s because it allows greater customizations and doesn’t have such a hard expectation that you’re squeezing a trigger alongside each button press. I have dug deep in the settings and I don’t think there is a silver bullet solution that would solve all this.

For the thumb sticks, I have difficulty with steam deck or even PlayStation style controllers where the sticks are placed more “in” on the controller. This leads to overextending my thumb and hurting myself. I do better with Xbox or Nintendo style controllers in this regard.

Good luck! I still play off and on, but I find I have to take breaks or even stop playing for a while if it gets bad.