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Overuse injuries

by Richard Norris, M.D.

Introduction

Overuse injures, are, unfortunately, all too common among instrumentalists. But the good news is that they are largely preventable. And when they do occur, most can be treated through a combination of proper care and a change in the habits or activities that caused them. All musicians, from casual players to seasoned performers, should learn the causes of overuse injuries in order to prevent their occurrence, and how to recognize the signs of such injuries at the earliest possible time.

First, what is an overuse injury? The condition occurs when any biological tissue - muscle, bone, tendon, ligament, etc. - is stressed beyond its physical limit. This results in micro-trauma to the body part; that is, microscopic tears which lead to small amounts of bleeding and swelling within the injured area. For instance, runners an d dancers frequently sustain stress or fatigue fractures, but musicians more commonly develop "tendinitis." The reason I put the word in quotes is that often the painful part is not the tendon itself, but the muscle which is attached to the tendon. However, since the word tendinitis is so familiar to musicians, we'll use it with the understanding that it refers to the muscle-tendon unit.

Overuse injuries are classified as acute or chronic. The acute overuse injury occurs when a musician learns a new phrase or trill and is determined to master it before going to bed that evening. He practices it over and over again for three or four hours, and the next day his hand or arm is stiff and painful. The chronic overuse injury takes place more insidiously over a longer period of time. Such is the tendinitis that is first evidenced as a very mild discomfort and over the course of weeks or months becomes progressively severe.

Predisposing Factors

There are at least ten general factors that predispose a musician to suffer from overuse injuries.

1. Genetic predisposition.
   Some people are probably more prone to overuse injuries, just as some are less resistant to catching colds. Statistically, young women seem most at risk for overuse injuries. The reasons are not clear, but perhaps since women are more likely to seek health care than men, they are disproportionately represented in the statistics. Or, perhaps because women's muscles are smaller, they are more susceptible to damage.
2. Inadequate physical conditioning.
   Muscles that are tight, weak, and inadequately stretched and exercised are more susceptible to overuse injuries than muscles that are strong and flexible. (This raises the separate topic of physical conditioning for musicians.) Physical education in music schools and conservatories has been sorely neglected Awareness of the importance of physical conditioning and exercise for musicians should increase in the next few years.
3. Sudden or abrupt increase in the amount of playing time.
   This is perhaps the most common cause of overuse injuries. They often occur during summer music camps where a student who has been playing three to four hours per day suddenly starts to play seven to eight hours per day.
4. Errors of technique.
   One of the most common technical errors is playing with excessive tension, which causes the muscles to work extra hard. This is particularly common in string players' left hands when bowing forte. Despite the increase in pressure at the bow, the left hand should not have to press down much harder than when playing piano.Often the player is not aware of this. Pressing down even 20-30% harder than necessary on the strings may have a cumulative effect, and result in a gradual, progressive overuse injury. In fact, tendinitis in the left forearm, particularly of the extensor muscles (the back of the forearm) is the commonest injury I see among violinists and violists in my practice. Problems with excessive tension in muscle force also occur in the neck and left shoulder area in fiddlers. This is often due to inadequate or improperly fitted chin and shoulder rests. An excessively high elbow on the bowing arm will lead to a predisposition towards right shoulder problems, as the tendons in the right shoulder get impinged between the arm bone and the shoulder bone. Cellists have the same problem if they don't rotate the cello slightly towards the right arm to facilitate bowing on the upper strings. Modern scientific techniques such as motion analysis, which has been used to evaluate the technique of professional and Olympic athletes, may also become widely available in the musical field to give us a better understanding of bowing and fingering techniques. This is already happening in some centers, along with studies of the muscles involved in such actions as vibrato.
5. Change in instrument.
   Switching from violin to viola, from one size viola to another, or to an instrument that has a different bridge height can all predispose toward overuse injuries. Whenever there is a change in instrument, the musician should back off slightly from his practice schedule and build up again over the course of a week or two. The same is true when changing repertoire or teacher.
6. Errors in practice habits.
   I feel that musicians should learn to regard playing their instrument as a physical activity. When asked about warm-up habits, people often report that they don't warm up at all, or consider simply playing scales or a few slow pieces as enough of a warm-up. One plays a musical instrument with the entire body. A good warm-up that includes the neck, arms, shoulders, upper and lower back, at very least, is important to prevent overuse injures. Exercises might include slow rolling of the head, both clock and counter-clockwise, slow shoulder shrugs and rolls, side bends, and torso twists. In general, practice sessions should be limited to about 45 minutes, with no less than a five-minute break to relax and shake out muscles. (One may continue to practice for several hours in this fashion.) Difficult passages or those that require awkward fingering should be practiced in small, short segments of not more than five minutes each. Go back and practice something else and then return to the difficult segment. This will help avoid overuse injures.
7. Inadequate rehabilitation of previous injuries.
   This factor is often overlooked. The tendinitis, muscle sprain, back or neck problem that has been treated just enough so that the person is able to resume playing, but is not completely resolved, is likely to flare up over and over again with any additional stress. It is important to pursue therapy until the player is completely free of pain, has full range of motion, and endurance, strength and coordination return.
8. Improper body mechanics and posture.
   This is where disciplines such as yoga and Alexander Technique are so important. A slumped posture and other poor body mechanics increase the risk of injury, particularly neck and back problems. This also applies to carrying instruments. Of course, the heavier the instrument, the more problems it presents, especially for a smaller person. In general, don't carry a heavy instrument with only one hand or hand it from one shoulder, as this creates undue strain on the shoulder and back. Instead, get a strap that is long enough to go over the head and across the chest. This distributes the weight of the instrument evenly. For heavier instruments there are backpack-type sacks or gig bags available. For even larger instruments such as cello and bass, use wheels on the bottom of the case when feasible. Observe proper body mechanics, such as bending from the knees and keeping loads close to the body, when lifting and carrying heavier stringed instruments.
9. Stressful non-musical activities.
   Refinishing furniture, pulling weeds, typing, knitting, or needlework can all result in tendinitis-like problems. As with playing an instrument, these injuries can be avoided by awareness, frequent rests, and moderation in duration and intensity of the activity.
10. Anatomical variations.
    String players may experience problems resulting from anatomical anomalies and exacerbated by the demands of a particular instrument. Examples are thoracic outlet syndrome (nerve or blood vessel compression at the base of the neck from an extra cervical rib), increased joint laxity or abnormal tendon connections or insertions.

Symptoms

How do you know if you have developed an overuse injury? The most common indicator is pain or discomfort. Overuse injuries are graded into five categories.

1. Pain at one site only, and pain that stops when playing stops.
2. Pain at multiple sites.
3. Pain that persists well beyond the time when the musician stops playing, along with some loss of coordination.
4. All of the above. In addition, many activities of daily living (ADL's) begin to cause pain.
5. All of the above, but all daily activities that engage the affected body part cause pain.

Nerve Compression

Numbness and tingling, the feeling of pins and needles, or electric shock-type sensations are usually indicative of nerve compression. This occurs most commonly at the wrist and is called carpal tunnel syndrome (CTS), which usually causes numbness and tingling in the thumb, index and middle fingers. CTS can be associated with a flexed wrist position, for instance as when playing in tenth position or above on the violin or viola. Here the wrist is extremely flexed, particularly on the viola. Avoid irritating the nerve at the wrist by practicing in the higher position only for short periods of time, if possible.

If the nerve compression occurs at the elbow, it is called cubital tunnel syndrome. The ulnar nerve which lies in the groove on the inside of the elbow (the so-called "funny bone,") is compressed, and when the elbow is bent (flexed) the canal or cubital tunnel narrows and the nerve is stretched at the same time. The left arm of the cellist when playing in the first position, and of the violinist and violist when playing in higher positions is particularly vulnerable. One possible reason for increased risk in string players is that the muscles that press the fingers down onto the fingerboard and bring the wrist in position to play in the higher positions on violin or viola surround the ulnar nerve at the elbow. When these muscles are working and contracting, they cause increased compression on the nerve in this area. Symptoms of cubital tunnel syndrome are not only pain in the elbow region, but numbness and tingling in the fourth and fifth fingers of the hand, where the ulnar nerve ends, and loss of coordination. Nerves can also be compressed in the neck, producing similar symptoms in the hand. Electrodiagnosis testing (EMG) can help pinpoint the sources of nerve compression problems.

Treatment

Perhaps the most important treatment is rest. We all know how difficult it is for professional musicians to take time off to rest, so we must borrow the concept of relative rest from sports medicine. This may mean cutting back on practice and performance rather than completely stopping. Of course, whether one must do this or not depends on the severity of the injury. For students there is less justification for not markedly cutting back or stopping playing for a brief period of time when necessary. It is better to postpone a jury or an audition than to play badly because of an injury. During the period of relative rest, technique should be assessed by a professional looking especially for areas of excessive tension or stress. If these are deemed significant factors by either the teacher or the physician, consider a stress management program that includes biofeedback training. Biofeedback can be used for both general muscle relaxation and while playing the instrument, so you can learn to relax the specific muscle groups that may be overworking. Alexander lessons may also be helpful.

Easy stretching exercises are also important to maintain length and movement in injured muscles and tendons. These should be preceded by gentle warmth to help relax the affected part. Stretching should be done only to the point of mild discomfort. As pain from the injury subsides, institute gentle strengthening exercises. This is best done under the supervision of an occupational or physical therapist, but may be continued at home if you are very judicious. Remember that muscles being strengthened are small, and it is better to proceed slowly and with caution than to risk re-injury. With forearm muscle tendinitis, pay special attention to strengthening upper arms, chest and trunk muscles.

Thermotherapy in the form of ice massage and gentle heat is often effective. Heat should be applied before stretching and strengthening, with ice used afterward for 5-10 minutes. Ice, rather than heat, should be used in acutely inflamed (hot) conditions. Anti-inflammatory medications such as Motrin, aspirin, Indocin and others may be used, but should never be the primary treatment. If there is a history of bleeding tendencies or stomach ulcers, be especially cautious when using these medications.

Activities of Daily Living

One of the most commonly overlooked reasons for treatment failure in what might appear to be an adequate treatment program is ignoring the effects of activities of daily living (ADL). When musicians complain of pain that accompanies ordinary activities such as brushing hair or teeth, opening doorknobs and the like coupled with inability to play for a number of weeks, I always refer them for a session or two with the occupational therapist. During these sessions, ADLs are evaluated and modified, and adaptive equipment is introduced if necessary. There are many adaptive devices developed to help people with severe arthritis that make ADLs easier on the arms and hands. These devices include built-up foam handles for eating utensils, writing utensils, hairbrushes and razors. Levers attached to doorknobs ease opening. Jar wrenches remove lids without force; key-holders prevent pinching the key between thumb and index finger when opening doors.

Driving can be very hard on the arms, particularly in a car without power steering or automatic shift. Drive as little as possible during recuperation. Musicians should avoid second jobs that require hand-intensive activities such as computer terminal operation, typing, waiting on tables, etc. As symptoms subside, resume normal daily activities gradually. Meticulous attention to minimizing or eliminating the stress of daily activities on the hand and arms can make the difference between success and failure in the treatment of overuse injuries.

Surgery or cortisone injections are rarely indicated, except for conditions such as carpal tunnel syndrome or certain types of tendinitis, such as at the base of the thumb, which often respond well to injection or surgery if conservative treatment is unsuccessful.

Splinting to rest the injured part is often helpful, particularly when the injury is in the dominant hand. It is very difficult for a right-handed person with tendinitis of the right arm to remember to use the other hand instead. To prevent hand use, the splint should come all the way out to the tops of the finger. Be careful, however, that you don't provoke injury in the opposite arm by the added, unaccustomed use of that side. Take the splint off several times a day to do gentle movements and muscle contractions that prevent stiffness and soreness of the splinted part. For maximum comfort and fit, have splints custom-molded by an occupational therapist.

In summary, the overuse injury which can be the bane of a student or professional musician can often be prevented or treated successfully in its early stages by increased awareness and recognition of the problem. Prevention, as always, remains the best medicine.

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©Strings Magazine. November/December 1989.

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