by Richard Norris, M.D.
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.
There are at least ten general factors that predispose a musician to suffer from overuse injuries.
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.
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.
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.
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.
©Strings Magazine. November/December 1989.
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