A commentary from author/cellist Janet Horvath
Chapter One: Overuse Injuries—Recognition and Prevention
Chapter Two: Nonsurgical Treatment of Upper Extremity Disorders in Instrumentalists
Chapter Three: Problems in the Neck Region; or When Making Music Is a Pain in the Neck!
Chapter Four: Thoracic Outlet Syndrome
Chapter Five: Back Problems in Musicians: Causes and Types
Chapter Six: Shoulder Problems
Chapter Seven: The Cubital Tunnel Syndrome: Nerve Entrapment at the Elbow
Chapter Eight: Carpal Tunnel Syndrome
Chapter Nine: De Quervain’s Disease: Tendinitis at the Base of the Thumb
Chapter Ten: Problems of Flutists
Chapter Eleven: The “Lazy Finger” Syndrome: Tendon Variations of the Pinkie
Chapter Twelve: Focal Dystonia (Occupational Cramp)
Chapter Thirteen: Therapeutic Exercises for Musicians
Chapter Fourteen: Returning to Play After Injury
Chapter Fifteen: Stage Fright and the Use of Inderal
A commentary from author/cellist Janet Horvath:
“We who play instruments know that there are few experiences in life that can be as fulfilling as making music. When giving to an audience, we are able to have positive influence not only on others, but also ourselves. When there is a synthesis of physical action, emotion, technique, and thought, music-making can reach incredible heights. But often our goals are thwarted by physical limitations and pain.
For decades, musicians have recognized the many factors—some unpleasant—that are essential to mastering an instrument: diligent practice, organization, discipline, travel to good schools, purchase of fine equipment, overcoming technical obstacles, isolation, loneliness, performance anxiety, etc. We seem to be able to deal with these. But it is only very recently that we are beginning to acknowledge another essential component: treating our bodies as part of our instruments, with the goal of preventing physical injury.
Thanks to doctors like Richard Norris who are working in the new field of performing arts medicine, we can now improve our physical approaches to our instruments with knowledge of how our bodies do the demanding tasks we ask of them. For many of us, a dream has come true. Musicians, both performers and educators, can now become more knowledgeable through conferences, publications, seminars, and books such as Dr. Norris's guide. We can now work towards prevention rather than correction.
You will find, as I have, that this down-to-earth survival manual is an invaluable resource and tool in our striving and yearning for freedom to play.”
Janet Horvath
Director, “Playing (less) Hurt”© Conference Series and Associate Principal Cellist, Minnesota Orchestra
The Musician's Survival Manual
A Guide to Preventing and Treating Injuries
In Instrumentalists
by
Richard Norris, M.D.
http://www.musiciansurvivalmanual.com/
Please see the website for a complete list of other Music Medicine educational products
Copyright© 1993, International Conference of Symphony and Opera Musicians (ICSOM).
Assigned (2007) and re-certified (2011)
International protection secured under Berne, UCC, Buenos Aires and bilateral copyright treaties.
Copyright 2011, Richard Norris, M.D. All rights reserved.
Smashwords Edition
ISBN: 978-1-4657-0938-7
Smashwords License Notes
This ebook is licensed for your personal enjoyment only. It may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each person you share it with. If you're reading this book and did not purchase it, or it was not purchased for your use only, then you should return to Amazon.com and purchase your own copy. Thank you for respecting the author's work.
No part of this book covered by the copyrights hereon may be reproduced, stored in a retrieval system, or transmitted-in any form or by any means now known or later developed without prior written permission of the publisher, except in the case of brief quotations embodied in critical articles and reviews.
For information contact: Dr. Richard Norris, through this book’s website.
Web site: http://www.musiciansurvivalmanual.com
Cover illustration: Peggy McHugh
First Edition Editor: Deborah Torch
Desktop publishing and additional graphics: Ken Ishii
E-book conversion/adaptation, 5th Edition editing: OPA Author Services, Scottsdale, AZ
Fifth edition: July, 2011 / First Electronic Edition: July, 2011
Foreword
To the college string teacher, it is both startling and alarming how often the studies and professional development of aspiring young musicians are significantly slowed or even brought to a halt by ailments affecting their arms, shoulders, and backs.
It is therefore encouraging that in recent years the medical profession has become increasingly interested in the problems connected with playing musical instruments.
Since the study of string instruments requires many hours of practice (besides the time spent in orchestra or chamber ensembles), this trend is of great importance to our students. Much more is now known and understood about the physical factors and activities involved in the playing of string instruments. Dedicated physicians with a special interest in music and musicians indeed deserve our gratitude for the advances in the relatively new field of performing arts medicine.
An outstanding example of such a physician is Dr. Richard N. Norris. I have had the pleasure of knowing Dr. Norris for a number of years and have learned that helping young musicians is quite clearly a passion for him. His work with numerous patients, as well as his popular course given at the New England Conservatory, has brought him into contact with a great number of string players and other instrumentalists. His course on health education for musicians, a pioneer venture for a major music conservatory, was offered for credit. The curriculum included aspects of anatomical, physiological, and physical education. Dr. Norris has also been extremely successful giving talks at music festivals and other summer music programs. All of these efforts have helped young musicians achieve far greater insights into the functioning of the body in relation to musical performance.
It is of course a logical further step to deal with the prevention of physical ailments. I believe that Dr. Norris's work in this respect, too, is of the greatest importance. The preventive measures and exercises he advocates are central to his approach. One can only hope that Dr. Norris's work will find wide dissemination among musicians.
Eric Rosenblith
Chairman, String Department, New England Conservatory
Faculty, Hartt School of Music, University of Hartford
Preface
This manual is not intended to be a scholastic work. It is a collection of monographs intended to assist musicians in understanding some of the medical problems that can occur and some of the principles of prevention. Most chapters are followed by suggestions for related reading which, although not necessarily used in preparation of the chapters, offer the reader sources of further information. The redundancy in some chapters is deliberate in order to help readers who may be encountering the material for the first time. I would encourage readers to make liberal use of “Google Images” to better understand the anatomy of the area being discussed. Simply cut and paste the name of the muscle or anatomic structure into the search box and find the corresponding images.
I hope that the reader will not be offended or put off by the use of the word “patient.” Lately, it has become fashionable to refer to people receiving medical or paraprofessional care as “clients.” According to Webster and other dictionaries, “patient” derives from the Latin root pati, which means “to suffer”; suffering is the usual reason to seek medical assistance. “Client” derives from the Latin verb clinare, which is “to lean” and refers to “a dependent; one who is under the protection of another, more powerful person.” To me, the term “patient” is the more descriptive and less pejorative of the two.
Some acknowledgements are in order. My gratitude to my editor Deborah Torch and to Ken Ishii, whose devoted and painstaking attention to text and graphics made this work possible; to ICSOM chairperson Brad Buckley for his support of the First Edition project; to music medicine doctors extraordinaire Bob Sataloff, Bob Markison, Hunter Fry, and Frank Wilson, for inspiring me; and to music educators Peter Row, Victor Rosenbaum, Tom Mastroianni, Janet Horvath, and Phyllis Curtin for their support of my efforts in promoting health education among musicians.
I wish to dedicate this book to my parents, Sidney and Priscilla Norris, both health educators and music lovers;and to the musical artists, past, present, and future, who have so enriched all of our lives.
Richard Norris
Chapter 1
Overuse
Injuries:
Recognition and Prevention
Click
on any chapter heading to return to the Table of Contents.
“No sort of exercise is so healthful or harmless that it does not cause serious disorders, that is, when overdone.”
~ Dr. Bernardino Ramazzini (1713)
Overuse injuries are, unfortunately, all too common among instrumentalists. Fortunately, however, such injuries are largely preventable and can often 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 how to prevent overuse injuries and how to recognize the earliest possible signs of such injuries.
What is an overuse injury? It's a condition that occurs when any biological tissue, such as muscle, bone, tendon, or ligament is stressed beyond its physical limit. This can result in microtrauma to the body part-that is, microscopic tears which lead to small amounts of bleeding and swelling within the injured area. Some studies (Fry) have revealed specific pathology. While runners and dancers frequently sustain stress or fatigue fractures, musicians more commonly develop “tendinitis.” Often, the painful part is not the tendon itself, but the muscle that is attached to the tendon. Thus, I use the word tendinitis to refer to injury of the muscle-tendon unit.
Overuse injuries can be classified as acute or chronic. An acute overuse injury occurs following a specific incident of stressing the tissue beyond its limits. An example would be a musician who learns a new phrase or trill and is determined to master it before going to bed that evening. He or she practices it for three or four hours, and then wakes up the next day with a stiff and painful hand or arm. Chronic overuse injury takes place more insidiously over a longer period of time. This tendinitis starts out as a very mild discomfort that becomes progressively severe over the course of weeks or months.
Predisposing Factors
There are at least twelve general factors that predispose a musician to suffer from overuse injuries:
Inadequate physical conditioning . Muscles that are tight, weak, and inadequately conditioned are more susceptible to overuse injuries than muscles that are strong and flexible. (Physical conditioning for musicians will be addressed in Chapter 13.) Physical education in music schools and conservatories has been sorely neglected in the past, but awareness of its importance is slowly increasing.
Sudden increase in the amount of playing time. An abrupt increase in playing time is perhaps the most common cause of overuse injuries. Injuries often occur during summer music camps when a student who has been playing three or four hours per day suddenly starts to play seven or eight hours per day. Preparing for recitals or juries, or taking extra gigs during a holiday season, can also lead to overuse injuries.
Errors in practice habits. Musicians should learn to regard playing an instrument as a physical activity. When asked about warmup habits, musicians often report that they don't warm up at all, or consider simply playing scales or a few slow pieces to be an adequate warmup. We play a musical instrument with the entire body. At the very least, a good warmup that includes the neck, arms, shoulders, and upper and lower back is important in preventing overuse injuries. Exercises might include slow rolling of the head, slow shoulder shrugs and rolls, side bends, and torso twists. In general, practice sessions should be limited to about forty-five minutes, with a break of no less than five minutes 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 short segments of not more than five minutes each. The musician should then move on to other material for a while before returning to the difficult segment. When a period of increased practice or performance intensity looms on the horizon, the best way to avoid overuse injuries is to increase practice time gradually over a few weeks.
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 playing forte. Despite the increase in bow pressure, 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 twenty to thirty per cent harder than necessary on the strings may have a cumulative effect, resulting in a gradual, progressive overuse injury. Tendinitis in the left forearm, particularly of the extensor muscles (along the back of the forearm), is the most common injury I see among violinists and violists in my medical practice. Drumsticks, horns, etc., are commonly gripped harder than necessary, as are steering wheels, pens, and telephones! Problems with excessive tension in muscle force also occur in the neck and left shoulder in violinists, often due to inadequate or improperly fitted chin rests and shoulder rests. 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 music field, leading to a better understanding of bowing and fingering techniques. Motion analysis, along with studies of the muscles involved in actions such as vibrato, is already available in some performing arts medicine centers.
Change in instrument. Switching from violin to viola, from electric bass guitar to string bass, or to a piano with stiffer action can all predispose to overuse injuries. Whenever there is a change in instrument, including upgrading to a better instrument, the musician should back off slightly from a normal practice schedule, and build up again over the course of a week or two. The same is true when changing repertoire or teachers.
Inadequate rehabilitation of previous injuries. An important factor that is often overlooked is prior injury. The tendinitis, muscle sprain, or neck problem that has not completely resolved, but has been treated or rested just enough so that the person is able to resume playing, is likely to flare up with any additional stress. It is important to pursue therapy until the player is completely free of pain, has a full range of motion, and has fully regained endurance, strength, and coordination.
Improper body mechanics and posture. Disciplines such as yoga, the Alexander Technique, and Feldenkrais body-work are very important in correcting slumped posture or other poor body mechanics that increase the risk of injury, particularly to the neck and back. Proper posture is also important in carrying instruments. Of course, the heavier the instrument, the more problems it presents, especially for a smaller person. In general, it is best not to carry a heavy instrument with only one hand or hang it from one shoulder, as this creates undue strain on the shoulder and back. A better way is to use a strap that is long enough to go over the head and across the chest in order to distribute the weight of the instrument evenly. For heavier instruments, there are backpacks or gig bags available. Wheels on the bottom of the case will help cellists and bassists. When lifting and carrying heavier stringed instruments, it is important to observe proper body mechanics, such as bending from the knees and keeping loads close to the body (see Chapters 5 and 6).
Stressful nonmusical activities. Refinishing furniture, pulling weeds, typing, knitting, or needlework can all result in tendinitis-like overuse problems. As with playing an instrument, these injuries can be avoided by awareness, frequent rests, and gradual increases in the duration and intensity of the activity.
Anatomical variations. Musicians, especially string players, may experience problems resulting from anatomical anomalies exacerbated by the demands of a particular instrument. Examples are thoracic outlet syndrome (nerve or b1ood vessel compression at the base of the neck from an extra cervical rib), increased joint laxity, or abnormal tendon connections or insertions (see Chapter 11) or variations in hand size and neck length.
Gender. Studies indicate that young women seem most at risk for overuse injuries (Fishbein and Middlestadt). The reasons are not clear; because men are less likely to seek health care, perhaps women are disproportionately represented in the statistics. Women's muscles are often smaller, and may therefore be more susceptible to overuse. This theory is supported by the fact that in the Fishbein and Middlestadt study, incidence of injury rises with increasing size of instrument. In my own practice, the majority of injured double-bass players I have seen were females, even though they constitute only a small proportion of all bassists. These findings should not discourage smaller persons from playing large instruments, but may indicate an increased need for awareness, good physical conditioning, and good practice habits.
Quality of instrument. A wind instrument with leaky valves or pads, a string instrument with a bridge or nut that is too high, or a piano that “speaks” poorly in the middle register necessitates extra or excessive force on the part of the player, with increased risk of injury.
Environmental factors. Inadequate lighting or poorly copied parts can cause eyestrain, but probably the most bothersome environmental factor is cold temperature. Playing evening concerts at outdoor music festivals in the Rockies or Berkshires towards the end of the summer or playing in stone cathedrals in midwinter can be chilling experiences! At low temperatures, nerve conduction slows, making it harder for the fingers to respond quickly. In addition, the fluid in the joints thickens, diminishing the sensitivity of the fingers. In this situation, the player needs to make sure he or she warms up adequately prior to play-a real physical warmup, not just scales. Appropriate dress is also important. Long sleeves and a high neckline may not be as stylish as a strapless gown for a female soloist, but may help avoid frozen hands. It may be necessary to wear longjohns under a tux, or even thin, fingerless gloves if playing in a pit.
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 (Fry):
pain at one site only, and only while playing;
pain at multiple sites;
pain that persists well beyond the time when the musician stops playing, along with some loss of coordination;
all of the above; in addition, many activities of daily living (ADLs) begin to cause pain;
all of the above, but all daily activities that engage the affected body part cause pain.
Most overuse injuries fall into grades 1, 2, or 3. The earlier the symptoms are recognized and treated, the sooner and more completely recovery occurs. In the earliest stages, overuse injuries may be experienced as stiffness without significant amounts of pain.
Nerve Compression
Numbness and tingling, the feeling of “pins and needles,” or electric shock sensations are usually indicative of nerve compression. This occurs most commonly at the wrist as 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, such as when playing in tenth position or above on the violin or viola. Practicing in the higher positions for only short periods of time, if possible, will avoid irritating the nerve at the wrist.
Nerve compression in the index finger is common in flutists (left hand), bass players who use a French-style bow grip, and mallet players. This problem is often misdiagnosed as CTS by physicians unfamiliar with musicians' injuries (see Chapter 8).
Compression of the ulnar nerve, which lies in the groove on the inside of the elbow (the “funny bone”), is called cubital tunnel syndrome (see Chapter 7). When the elbow is bent (flexed), the canal of the cubital tunnel narrows and the nerve is stretched at the same time. The left elbow of the cellist (in the first few positions) and the right elbow of the piccolo player are particularly vulnerable due to the maximally flexed position. In the “chin strings,” the rotated (supinated) and flexed position of the left arm, especially in the higher positions, also stresses the ulnar nerve at the elbow. One other factor for increased risk in string players is that the flexor carpi ulnaris muscle, which positions the wrist to play in the higher positions on violin or viola, surrounds the ulnar nerve at the elbow. When this muscle is working and contracting, it causes additional compression on the ulnar nerve.
Besides pain in the elbow region, symptoms of cubital tunnel syndrome include numbness and tingling in the fourth and fifth fingers of the hand, where the ulnar nerve ends; loss of coordination; and, in severe cases, muscle wasting (atrophy) of the small muscles of the hand.
Nerves can also be compressed in the neck or thoracic outlet region (see Chapter 4), producing similar symptoms in the hand. Electrodiagnostic testing 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. Depending on the severity of the injury, this may mean cutting back, rather than completely stopping, practice and performances. For students, there is less justification for not markedly cutting back or stopping for a brief period of time when necessary. It is better to postpone a jury or an audition than to allow an injury to worsen.
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, the musician would do well to consider a stress management program that includes biofeedback training. Biofeedback can be used for both general muscle relaxation and for playing an instrument, so one can learn to relax the specific muscle groups that may be overworking. Video feedback-watching oneself on a video monitor while working with a posture or movement specialist-is an effective tool; a permanent tape of the session can be made for further review. Alexander or Feldenkrais lessons are often helpful.
Gentle stretching exercises to maintain length and movement in injured muscles and tendons are also important (see Chapter 2), and 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, gentle strengthening exercises may be instituted. Although it is preferable to do these exercises under the supervision of an occupational or physical therapist, very judicious patients may continue at home. When the muscles being strengthened are small, it is better to proceed slowly and with caution than to risk reinjury. With forearm muscle overuse, special attention should be paid to strengthening muscles of the upper arms, chest, and trunk.
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 five to ten minutes. Ice, rather than heat, should be used in acutely inflamed (hot) conditions. Anti-inflammatory medications such as ibuprofen and naproxen may be used, but should rarely be the primary treatment. Persons with a history of bleeding or stomach ulcers should 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 therapy program is the effect of activities of daily living (ADLs). 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 an occupational therapist. During these sessions, ADLs are evaluated and modified, and adaptive equipment is introduced if necessary. For people with severe arthritis, there are many adaptive devices 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 the thumb and index finger when opening doors. For additional information about finding and ordering adaptive equipment for daily activities, visit http://www.pattersonmedical.com/ (look for ‘aids to daily living’ in the ‘Online Catalog’ section near the topof the left hand column on the home page)
As driving can be very hard on the arms, particularly in a car without power steering or automatic transmission, one should drive as little as possible during recuperation. Musicians should also avoid second jobs that require hand-intensive activities such as computer terminal operation, typing, waiting on tables, etc. Normal daily activities may be resumed gradually as symptoms subside. Meticulous attention to minimizing or eliminating the stress of daily activities on the hands and arms can make the difference between success and failure in the treatment of overuse injuries.
Surgery or cortisone injections are only rarely indicated. However, conditions such as carpal tunnel syndrome or tendinitis at the base of the thumb (de Quervain's disease) often respond well to injection or surgery when conservative treatment has been unsuccessful.
Splinting to rest the injured part is often helpful, particularly when the injury is in the dominant hand. A right-handed person with tendinitis of the right arm often has trouble remembering to use the left hand instead. To prevent use of the injured hand, the splint should come all the way out to the tips of the fingers (full-length resting splint). Care must be taken not to provoke injury in the opposite arm by the added, unaccustomed use of that side. Removing the splint several times a day to do gentle movements and muscle contractions will prevent stiffness and soreness of the splinted part. Splints custom-molded by an occupational therapist may provide maximum comfort and optimal fit. Slings should be avoided, if possible, as there is some risk of ulnar nerve compression from prolonged elbow flexion, in addition to risking neck strain from supporting the weight of the arm with the neck muscles.
Summary
The overuse injury that 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.
Suggested Reading
Bird H. Overuse injuries in musicians. British Medical Journal 1989 Apr 29; 298 (6681): 1129-30.
Fry HJH. The effect of overuse on the musician's technique: a comparative and historical review. International Journal of Arts Medicine 1991 Fall; 1 (1): 46-55.
Fry HJH. How to treat overuse injury: medicine for your practice. Music Educators Journal 1986 May; 72(9): 46-49.
Fry HJH. Patterns of overuse seen in 658 affected instrumental musicians. International Journal of Music Education 1988; 11: 3-16.
Fry HJH. Prevalence of overuse (injury) syndrome in Australian music schools. British Journal of Industrial Medicine 1987 Jan; 44(1): 35-40.
Fry HJH. Treatment of overuse syndrome in musicians: results in 175 patients. Journal of the Royal Society of Medicine 1988 Oct; 81 (10): 572-75.
Goodman G; Staz S. Occupational therapy for musicians with upper extremity overuse syndrome: patient perceptions regarding effectiveness of treatment. Medical Problems of Performing Artists 1989 Mar; 4(1): 9-14.
Lederman RJ; Calabrese LH. Overuse syndromes in instrumentalists. Medical Problems of Performing Artists 1986 Mar; 1(1):7-11.
Lockwood AH; Linsday ML. Reflex sympathetic dystrophy after overuse: the possible relationship to focal dystonia. Medical Problems of Performing Artists 1989 Sep; 4(3): 114-17.
Newmark J; Lederman RJ. Practice doesn't necessarily make perfect: incidence of overuse syndromes in amateur instrumentalists. Medical Problems of Performing Artists 1987 Dec; 2(4): 142-44.
Chapter 2
Nonsurgical
Treatment
Of Upper Extremity Disorders
In Instrumentalists
Click on any chapter heading to return to the Table of Contents
Fortunately, most upper extremity injuries of musicians respond to conservative treatment. Fewer than five per cent of injuries require surgical referral and evaluation; of these, fewer than half actually receive a surgical procedure. The most common reason for surgical referral is nerve entrapment.
Nerve Entrapments
The common compressions or entrapment neuropathies occur at the carpal tunnel, cubital tunnel, and thoracic outlet. Ulnar nerve entrapment at the wrist (Guyon's canal), pronator teres syndrome, radial sensory branch neuropathy, and neurogenic thoracic outlet syndrome are relatively uncommon. (Please feel free to look up these less common syndromes if you are interested.)
Carpal tunnel syndrome has multiple etiologies, including pregnancy, amyloid disease, and underlying diabetes. However, this discussion will be limited to occupational carpal tunnel syndrome. Gelberman has shown marked increase in carpal tunnel pressures with extremes of both flexion and extension of the wrist. This often relates directly to musical technique. Therefore, one of the first considerations in treating carpal tunnel syndrome is markedly reducing playing time, or at least avoiding positions that require sustained or repetitive flexion or extension of the wrist. Electrodiagnosis is often extremely useful in assessing both the site of the entrapment and the severity and prognosis.
The mainstay of conservative treatment for carpal tunnel syndrome is splinting, and, as was mentioned, avoiding offending activities. The splint should put the wrist in the functional position, allowing 0° to 5° of extension, leaving the fingers free. Depending on the severity of the symptoms and clinical findings, the splint may be worn only at night or throughout most of the day as well. The splint should be taken off several times a day for the musician to do gentle pain-free, range-of-motion exercises. Oral anti-inflammatory agents may be helpful, as may injection of a steroid preparation mixed with a local anesthetic. It is my personal preference to use soluble steroids, rather than Depo or long-acting steroids, because hand surgeons have found steroid crystals in the carpal tunnel weeks to months after an injection with Depo steroids. These crystals may eventually be mechanically irritating.
If conservative treatment is unsuccessful after a period of six to eight weeks, and/or electromyography (EMG) shows signs of muscle denervation, surgical referral may be indicated. An Orthopedic Hand surgeon or a Plastic surgeon is preferable, as is the newer endoscopic surgical release which leaves a tiny scar over the wrist, not the palm of the hand. There is also some evidence, although inconclusive, that vitamin B6 may be therapeutic.
Cubital tunnel syndrome may be more prevalent in string players, particularly cellists and violinists, due to the nearly continuous extremes of elbow flexion in the left arm when playing those instruments. The cubital tunnel is located on the inner aspect of the elbow; thus, when the elbow is flexed, the ulnar nerve is stretched around the elbow, and the cubital tunnel is narrowed. Both factors are potential causes of irritation of the ulnar nerve within this region. For violinists, an additional risk factor is that the ulnar nerve is surrounded by the two heads of the flexor carpi ulnaris muscle-the very muscle used to play in higher positions on the violin. The floor of the cubital tunnel is formed by the flexor sublimus muscle, which is strongly contracted in playing both violin and cello.
Treatment for cubital tunnel syndrome consists of splinting the elbow in extension, although not necessarily with a rigid splint: a hinged splint that allows not more than 90° of elbow flexion (flexion = bringing the fist toward the shoulder) is best. Again, if there are signs of denervation, or if symptoms either worsen or fail to resolve within about three months, surgical consultation may be indicated if symptoms are severe.
Tendinitis
Of all the upper extremity disorders in instrumentalists, pain syndromes of the muscle-tendon unit seem to be the most common. A multitude of treatment options have been found to be beneficial. The first and most important is relative rest. As in sports medicine, a goal of performing arts medicine is to try to keep patients playing, to the extent possible. Often, it is not necessary to cease playing, but simply to reduce and modify the playing schedule. This may take a bit of experimentation, but certainly the patient should be instructed to avoid playing to an extent that aggravates the injury. The threshold may vary from a few minutes to a few hours per day. If any amount of playing causes pain or aggravation of symptoms, then the rest should be as complete as possible. Once symptoms have abated, it is imperative that the return to playing be gradual. Relative rest really means avoiding pain-producing activities.
In its extreme form, rest may include immobilization, which is certainly not a benign treatment. Muscles need to contract and relax periodically, while joints depend on motion for cartilage·nourishment. Perhaps the chief indicator for immobilization is pain on use of the hand in any daily activities, especially when the patient seems unable to stop using an injured dominant hand in activities of daily living. A full-length resting splint (from the tips of the fingers to the mid-forearm) often is required to preclude hand use. Removing the splint several times a day to perform gentle pain-free, range-of-motion exercises should prevent stiffness and worsening of symptoms.
Return to Playing
Returning too rapidly to prior levels of practice and performance is one of the most common pitfalls of the rehabilitation process. A written, individualized training schedule is very helpful in giving the performer guidelines to follow (see Chapter 14). Generally, in the initial stages, practice periods should be brief and rest periods long. As the injury heals, practice periods can grow progressively longer and rest periods shorter, and the patient can go from playing slow tempos and easy material to faster tempos and harder material. Sudden increases in performance time must be avoided.