Assessment and Treatment Principles for the Upper Extremities of

Assessment and Treatment Principles for the Upper Extremities of
Assessment and Treatment
Principles for the Upper
Extremities of
Instrumental Musicians
Performance-related issues are discussed, followed by
assessment and treatment techniques for
tendinopathies, hypermobility, and focal hand dystonia.
Other conditions covered include nerve entrapment
syndromes and ganglions.
Ideas are presented regarding orthotic intervention,
musical ergonomics, warm-up and cool-down exercises,
and an example of a graded return-to-play program.
Environmental factors and anatomic variations that can
affect musicians are mentioned briefly.
The four surgical principles that need to be considered
when operating on musicians are listed as well as a
discussion on using the musical instrument as a
rehabilitative tool.
Musicians’ hands are vital to their musical performance.
Musicians often have to perform to the limit of their abilities
physically, emotionally, and spiritually. They utilize rapid,
complex, coordinated movements. Sometimes they are
required to play in less than ideal environments and usually
they do not have a medical team to support them in the way
sports medicine supports athletes. Musicians can be required
to play long tours with poor facilities. Noise, drug and alcohol
use, and pressures can be high. They frequently injure
themselves or acquire injuries that can lead to difficulties or
an inability to play their instrument.
Over the last 20 years musicians’ medicine has become
increasingly popular, with at least six textbooks relating to
this topic published in English. Professional groups and organizations have been established in numerous countries to
research preventative measures and effective treatments that
are tailored to musicians. Each country has specific circumstances (e.g., health-care system, available financial support,
and perceived medical need) that influence the administrative structure of the performing arts organizations.
Additionally, alongside national initiatives, there is a growth
in international cooperation, assisted by the development of
international conferences.1
Specialist assessment and rehabilitation techniques are
required when dealing with this patient group. An understanding of the instrument and the type of music played is
imperative. An area of specialization that has come to the fore
in musicians’ medicine is hand therapy.
The focus of performing arts medicine should be prevention. Wynn Parry2 has made a detailed analysis of the 1046
musicians he has personally seen at British Association of
Performing Arts Medicine (BAPAM) clinics (Fig. 142-1).
Clear-cut pathologies in which a specific diagnosis can be
made were evident in 48% of this group. Of the structural
disorders, four broad bands were evident: old injuries (22%),
tenosynovitis (12%), hypermobility (9%), and focal hand
dystonia (5%). In the remaining 52% few physical signs could
Old injuries
Focal hand
Figure 142-1 Percentage breakdown of specific versus nonspecific
diagnosis for injured musicians. (Data from Wynn Parry CB. Managing the
physical demands of musical performance. In: Williamon A, ed. Musical
Excellence Strategies and Techniques to Enhance Performance. Oxford,
U.K.: Oxford University Press, 2004: 41-60).
include failure to take at least a 5- or 10-minute break every
hour of practice. Practice of physically difficult or awkward
passages should be limited to short segments of 2 to 3 minutes
each within a practice session.
A physical warm-up and cool-down before and after
playing is desirable and seen as being essential. The neck,
shoulders, and arms should be the focus areas. This might
include slow rolling of the head and neck, shoulder shrugs,
side bends, and torso twists.6 If the musician plays an instrument, such as the violin, viola, or flute, that requires constrained postures, these sessions are of particular importance.
Much time is spent with patients discussing “graded-returnto-play” programs and practice techniques, which are discussed later in the chapter.
Change in Instrument
be found, and the symptoms were seen as being very vague,
general, and due to performance-related issues such as incorrect practice or playing techniques.
Performance-Related Issues
Nontrauma-related conditions need careful analysis and consideration, and thus hand surgeons or therapists may be able
to assist with providing an anatomic diagnosis for a painful
condition in a musician’s hand or arm.3 Some conditions may
result from
• excessive training
• change in instrument
• quality of instrument
Excessive Training
Abrupt increase in practice or performance time is perhaps
the most common risk factor.4 This can occur while attending a summer academy, preparing for a recital or competition, during holiday seasons when performers may be in
increased demand, or when an amateur decides to intensify
study. Newmark and Lederman5 carried out research on
musicians at a conference. Only two players were professional musicians and 73% (79/109) did not usually practice
routinely and had a rapid increase in playing time and so
were predisposed to overuse injuries. Of those affected by the
significant increase in practice time 61% (48/79) developed
new playing-related complaints, whereas 34% (27/79) experienced problems even without a significant increase in
playing time. The authors comment that musicians should
view themselves as athletes, be more attentive to their physical limitations, condition their bodies accordingly, and work
at preventing overuse injuries. They hope that teachers, performers, and physicians learn from the experiences of their
respondents and implement a carefully planned increase to
playing time.
“Correct” practice technique is imperative. Musicians frequently overpractice, which can have a negative effect on the
individual’s whole body—particularly the hands and upper
limbs. During long practice sessions, the instrumentalist may
begin to use suboptimal body mechanics, which most frequently affect the hands and arms.3 Training errors often
Changing from violin to viola (increasing the size of the
instrument), electric bass to string bass (increasing the length
of the fingerboard and required finger span), synthesizer to
acoustic piano (increasing the force requirements for sound
production), flute to piccolo (decreasing hand span and
finger spacing), bassoon to contrabassoon (increasing the
weight of the instrument and the hand span), or from a standard drum set to an “extended” set (increasing upper extremity reach requirements) represents the range of possible
changes and how those changes can affect the upper extremities. These changes may predispose the musician to injury,
especially if combined with an abrupt increase in playing
time. The solution is to decrease the intensity of practice
when such a change is made, and then to gradually build to
the desired level of play. A change in teacher or style of music
performed may result in a change in technique, which then
requires a similar modification to the intensity of practice.
Quality of Instrument
Leaking keys or valves on a poorly maintained wind instrument can result in increased fingertip pressure required to
produce a clean sound. Bridges on string instruments that
are too high can increase the force needed to depress the
strings. A piano in poor condition may require more force to
achieve the desired dynamics and subtleties in sound, color,
dynamic, and shade. Animal studies have shown that highly
repetitive motor movements can contribute to degradation in
the somatosensory cortex.7 However, Byl and associates7
comment that when the speed and force of the repetitive
motor task is varied and interspersed with other regular
activities, the degradation of hand cortical representation and
loss of motor control can be minimized. Thus, it is important
to maintain instruments in top playing condition, with the
hope of decreasing excessive energy outlay for the desired
level of performance.8 Musicians need to intersperse practice
and playing with other activities in order to decrease the
chances of developing medical conditions.9
Nonmusical Activities and Factors
A musician may have excellent technique and practice habits,
but may sustain upper extremity trauma from a variety of
nonmusical activities. Musicians can suffer trauma while
engaged in sporting or home hobby activities. These injuries
need to be managed within the context of their instrument
and the demands placed on their hands. Sports such as volleyball and martial arts are correlated with a particularly high
incidence of hand injuries.10,11 Other hand-intensive activities
that may cause problems include knitting, needlepoint, woodworking, fly tying and fishing, writing, and computer use.
Environmental Factors
Cold temperatures produce a number of adverse effects on
musicians’ limbs. Cutaneous sensitivity decreases in the
cold, which may lead to the use of excessive fingertip pressure, an increase in joint fluid viscosity, slowing of nerve
conduction velocity, and diminished blood flow because of
vasoconstriction. These effects may occur in spite of increased
muscular demands. Players must guard against these effects
by whatever means available, including wearing thermal
underwear under their performance clothes, layering clothes,
using fingerless gloves, or placing a heater in the practice
Anatomic Variations
Anatomic variations range from the obvious to the subtle.
Obvious ones, such as small stature or hand size, can be a
problem when playing large or awkward instruments or
certain pieces of music composed by persons with unusually
large or flexible hands, such as Paganini or Rachmaninoff.
An example of this can be seen in Figure 142-2.
A troublesome subtle variation is positive ulnar variance,12
which can cause an impingement syndrome when playing
instruments requiring ulnar deviation—for example, certain
fingers in the piano, harp, matched grip with the drums, the
left hand in the trumpet, and at the end of the up-bow
passage in stringed instruments. For musicians playing these
instruments, accessory tendons in the first dorsal extensor
compartment can predispose to de Quervain’s disease.
Tendinous interconnections between the flexor digitorum
superficialis of the fourth and fifth fingers13 can lead to severe
problems if they occur in the left hand of violinists or violists
(Fig. 142-3).14 Cervical ribs may cause problems on the left
side in string bass players or musicians who are required to
flex or rotate their neck while playing instruments such as
the viola, violin, or flute.
© K.Butler2009
Figure 142-2 A, Cornetto player displaying wrist and elbow positioning. This patient presented with ulnar nerve symptoms and intrinsic
muscle strain in both hands, probably due to long-term positioning of
both upper extremities in awkward positions because of the constraints
of the instrument. B, Small hand size with limited finger span resulting in
intrinsic muscle strain.
• Mechanical—Perhaps the tendon has been overloaded,
causing damage to the extracellular matrix, which in
turn has caused a failed healing response in the
• Vascular—Tissue hypoxia may decrease the viability of
tendon cells, and as the tendon reperfuses, oxygen free
radicals are released, possibly leading to a pathologic
tendon. Free radicals are associated with ageing,22,23
neurodegenerative diseases,24 chondral and meniscal
lesions,25 and tendon degeneration in rats.26 If this
hypothesis is valid then the possibility of treating tendinopathies with antioxidants is raised.
• Neural—There may be a neurogenic origin to diseased
tissues as mast cell degranulation and release of substance P has been implicated and found in degenerative
Clear-Cut Pathologies
Affecting Musicians
Tendinopathies are a common degenerative rather than
inflammatory condition. Histopathologic surgical specimens
show a lack of inflammation.15-18 The term tendinopathy
should be used rather than tendinitis, tendinosis, paratendinitis, or tenosynovitis, as this term refers to the primary
symptomatic tendon disorder and has no implication of
pathology.19 The cause of tendinopathy is unclear but three
broad ideas cover possible methods of development:
© K.Butler2009
Figure 142-3 A, The wrist flexion and forearm hypersupination
required to reach the higher positions on the viola. B, The size of the
instrument relative to the individual can influence the ease of playing and
the possibility of the musician being predisposed to developing medical
Butler and Sandford19 outline the intrinsic and extrinsic
factors that can lead to tendinopathies developing.
• Intrinsic factors include:
• Age—mostly affects people older than 30 years of age
• Nutrition—predominately affects people with poorer
nutrition levels
• Anatomic variations—affects people with extra long
tendons or individuals who have two tendons in one
tendon sheath
• Joint laxity—hypermobile patients are more frequently
• Gender—women are more often affected than men
• Systemic disease—diabetic patients are more commonly affected
• Extrinsic factors include:
• Occupation—if you work in confined spaces or perform
repetitive movements
• Sport/hobby—if forceful repetitive movements or sustained postures are required27
• Physical load—if heavy loads are required to be repeatedly moved
• Equipment—if the equipment is not well maintained, of
poor quality, or inappropriate to the individual
• Rapid increase in work load—if the work load is
intense, fast-paced, and pressurized
• Environment—if the environment is too cold, too hot,
cramped, or pressured
De Quervain’s Disease
De Quervain’s disease is a stenosing tenovaginitis of the abductor pollicis longus and extensor pollicis brevis.28 These two
muscles commonly share a tendon sheath and, although the
tendons are entirely normal and no inflammation is present, a
cross section of the fibro-osseous channel shows diminishment of the channel and fibrotic thickening of the extensor
retinaculum.16 Clinical examination shows swelling, thickening, and pain of the first dorsal compartment. There is pain on
resisted thumb extension and abduction, and weak pinch
grip.29 A Finkelstein test is positive. There are no reliability
studies for this test, but it is commonly utilized in the clinical
setting.30 Differential diagnosis for de Quervain’s disease
includes first carpometacarpal joint osteoarthritis, scaphoid
fracture, intersection syndrome, superficial radial nerve irritation (Wartenberg’s syndrome), and central referral.19
Other tendinopathies include lateral and medial elbow
pain, trigger finger, and carpal tunnel syndrome.
Treatment Principles for Tendinopathies
Patient education, ergonomic advice, activity modification,
biomechanical considerations, electrotherapy, acupuncture,
ice, strengthening, stretching, myofascial release, trigger
point therapy, orthotic positioning, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), local steroid
injections, and surgery are all possible treatments for the
symptomatic patient.
Patient Education
The patient with a tendinopathy or muscular strain who rests
just enough to keep playing, but manifests lingering symptoms, can develop a chronic condition that flares up repeat-
edly until adequate rehabilitation is received. Requirements
for adequate rehabilitation include full range of motion
(ROM), minimum pain on palpation of the muscle bellies
or tendon origins and insertions, reasonable normative
maximum grip strength, good endurance rates, and high
levels of coordination. The musician must be aware that the
length of the healing process is in months rather than weeks,
and that the key to getting better and staying better is to
modify the way the task is being performed as this may be
predisposing to the condition.
Activity Modification and Ergonomic and
Biomechanical Considerations
Some awkward postures are probably unavoidable, but some
are related to poor instrumental ergonomics and technical
difficulties.31 Marked wrist deviation32 and excessive fingertip
loading can lead to increased tissue stresses33 and elevated
pressures in the carpal tunnel.34,35 The use of excessive force,
whether it be gripping drumsticks, pressing down on strings
or keys, or clenching the violin between neck and shoulder,
increases the risk of soft tissue injury.36 Carrying heavier
instruments can strain the hands. Using wheels or backpackstyle straps on cases can effectively reduce the carrying load
placed on the limbs.
Many adaptive devices and cases have been specifically
designed to decrease joint strain, distribute the load of the
instrument, or protect the instrument and yet be lighter and
more ergonomically sound. Some examples of such supports
are shown in Figure 142-4.
Computer Use
Computer use is ubiquitous, often ergonomically unsound,
and frequently intense, especially among students. The musician must be counseled to minimize computer use, especially
during periods of intensified musical activity. Optimal ergonomic positioning while at the computer should be enforced
for all patients, and keyboard short cuts should be used
wherever possible in order to decrease the total number
of keystrokes made during a session at the computer
(Fig. 142-5).
Here are some general concepts that are readily accepted
when using a computer keyboard and mouse:
• Keep wrists neutral.
• Don’t rest wrists while typing.
• Move the whole arm while keying.
• Avoid stretching the fingers to reach keys that are
far away.
• Keep fingers curved and relax the thumb.
• Use a light touch.
• Keep fingernails short.37
• Avoid double clicking as much as possible when using
a mouse.
Myofascial Pain and Stretching
Myofascial pain may be due to overactivity of motor end
plates in muscles, which results in distinct referral patterns
of pain. For example, a tender point or trigger point in the
brachioradialis can refer to the elbow, thumb, and dorsum of
the hand. Treatment can include trigger pointing, soft tissue
massage, stretching, icing, acupuncture, home acupressure,
© K.Butler2009
Figure 142-4 A, Ton Kooiman “Etude” clarinet thumb rest. B, A support for the left index finger of a flautist that assists in maintaining the metacarpophalangeal joint in a more neutral position. C, Fully adjustable A-frame guitar leg support that has been padded with Velfoam to decrease pressure
on the upper thigh. D, Fully adjustable Ergoplay guitar support attaches to the classical guitar and elevates it so that the musician can play with both
feet firmly on the floor and avoid using a foot stool.
and activity modification (e.g., how to carry items, and sleeping positions that assist in decreasing symptoms). See Figure
142-6 for examples of possible forearm flexor and extensor
muscles stretches.38
It must be noted that although these stretches can be
useful for most musicians, hypermobile individuals must not
go into their hypermobile range, but rather keep the elbow
slightly flexed while performing the exercises.
Musicians seem to have a higher incidence of hypermobility
than the population at large.2 Increased range can be very
advantageous to musicians such as string players and pianists. Indeed some very virtuosic players such as Paganini
and Liszt were hypermobile. Larson and colleagues39 studied
660 musicians and concluded that hypermobility in the
fingers, thumb, and wrist may be an asset when playing
repetitive motions on instruments such as the flute, violin,
or piano. This author went on to say, however, that
hypermobility may be a limitation when the joints are
required to be stabilizers—for example knee joints for
timpanists who stand to play. Larson and coworkers40
showed that musculoskeletal symptoms associated with practice and performance may be due to the lack of hypermobility
of some joints involved in intensive repetitive movement.
Subjects who played instruments requiring repetitive motion
reported fewer symptoms in their joints if they were
Jull41 states that for many musicians hypermobility is an
impediment. The weakness in muscle power and increased
vulnerability of the associated joint can lead to an increased
propensity for these musicians to develop injuries or chronic
“overuse” syndromes. There is evidence to suggest that
hypermobile joints have a decreased sensitivity to proprioception,2 so musicians may exert more force than necessary
on keys or strings, thus increasing the possibility of chronic
Hypermobility and the Role of
Hand Therapy
Patients are routinely assessed for hypermobility in the initial
examination, using the nine-point Beighton score42 and
involving the following features:
© K.Butler2009
Figure 142-5 A, Incorrect wrist and finger position resting on computer keyboard gel wrist support. B, Correct arm, wrist, and finger position at the keyboard. C, Correct ergonomic set-up for working at the
• Dorsal flexion of the fifth metacarpophalangeal (MCP)
joint at 90 degrees. One point for each hand equals two
possible points.
• Ability to appose the thumb to the radial aspect of the
forearm. One point for each thumb, equals two possible
• Hyperextension of the elbow beyond 10 degrees. One
point for each elbow, equals two possible points.
• Hyperextension of the knee by 10 degrees. One point
for each knee, equals two possible points.
• The ability to put the hands flat on the floor with
the knees extended when bending forward. One
possible point.
Assessment on the instrument is imperative, as hyperlaxity may be more evident while the musician is playing.
Brandfonbrener43 consistently found a correlation between
musicians with hand and arm pain and the presence of joint
laxity. Whether or not the hypermobility is the primary cause
of symptoms, joint protection advice is always provided.
Specific exercises can be helpful, and many adaptive ways of
performing tasks can be incorporated into the patient’s
© K.Butler2009
Figure 142-6 A, Forearm flexor stretch. With the elbow straight, and
palm facing upward, gently move your wrist backward, using your own
muscle strength until you feel a stretch. Then, with the other hand, gently
pull the wrist further backward by placing light pressure in the palm. Hold
this stretch for 10 seconds. B, Forearm extensor stretch. With the elbow
straight and palm facing downward, gently bring the wrist and fingers
in toward you using your own muscle strength until you feel a stretch.
Then with the other hand, lightly push on the back of your wrist, bringing
it further toward you. Hold this stretch for 10 seconds.
Advice and adaptive task performance can prevent injuries
from developing and ensure that the performer is more able
to have a generally more fulfilling and less painful time especially when playing their instrument. Patients can benefit
greatly from a rehabilitation program to improve muscle
power.44 The stability-strengthening exercises encourage
co-contraction of the muscles surrounding a joint. Isometric
strengthening and proprioception exercises both on and
away from the instrument can assist in achieving this goal
(Fig. 142-7).
Therapeutic putty exercises can be very useful in increasing intrinsic muscle strength and proprioceptive awareness.
Orthotic positioning options are discussed later in the
When exercising away from the instrument, initial stability exercises include isometric muscle contraction in a painfree range while wearing a support. Later in the rehabilitation
phase, exercises can be progressed to include concentric and
eccentric strengthening. Isometric strengthening exercises
on the instrument can be a useful tool—for example exercises in the neutral joint position while holding the bow,
string instrument, or clarinet.45 Proprioception exercises and
retraining such as tapping exercises and weight-bearing exercises in a neutral position should be performed first with the
eyes open and then with the eyes closed. After months of
performing strengthening exercises, symptoms can improve,
and it is not uncommon to detect an improvement in ligament tautness with joint translation testing. It is encouraging
Stability Exercises
for the hand and wrist
These exercises do not involve any movement but are static and resisted.
Support the length of your forearm on a table.
You should feel resistance rather than pain, and only use 30%–50% of your maximal effort.
Hold each position for 5–10 seconds, increase as tolerated up to 30 seconds.
Forward bending
Backward bending
With the palm of your hand
facing down and your hand
forming a light fist, push your
forearm into the table and feel
the resistance right up into
your upper arm.
With your affected wrist in a
neutral plane and whilst
forming a light fist, place your
unaffected hand over the
back of the wrist and resist
the backwards movement.
Repeat ___ times ___ per day
Repeat ___ times ___ per day
Side to side
Rest your hand and forearm
with the palm facing the table
and make a light fist. Resist
movement toward the thumb
with the palm of the other
Rest your hand and forearm
with the little finger in contact
with the table. Make a light fist
and push the side of your
forearm into the table.
Repeat ___ times ___ per day
Repeat ___ times ___ per day
Rest your hand and forearm
with the little finger in contact
with the table, resist against
your affected side using your
other hand. Place your
unaffected hand over the base
of your wrist. Imagine you are
turning your palm down
toward the table and resist this
movement without moving the
© K.Butler2009
Repeat ___ times ___ per day
Figure 142-7 Patient handout showing stability exercises for the wrist and forearm.
for the musician to be told that biomechanical dysfunction
can be improved.
The intrinsic and extrinsic muscles of the hand are frequently stressed in an attempt to compensate for joint instability.43 Strengthening exercises using therapeutic putty can
be useful when treating hypermobile patients. Treatment
must focus on stability-strengthening exercises, temporary
supports, sensorimotor retraining to improve proprioception, and patient education regarding good practice habits
and healthy joint use.45 Temporary supports to maintain
the joint in a neutral position are useful for playing, and the
patient should be gradually weaned as strength increases and
symptoms decrease. Supports can include light thermoplastic
orthoses, neoprene wraps, wrist braces, Lycra finger sleeves,
or a Coban wrap. It may take many months for stability
strength to improve enough for a modified playing schedule
to be instigated. Temporary orthoses or wraps may need to
be worn for some time. Exercises must be continued until
enough muscle strength has been gained or orthotic use
continued until a neutral joint position can be maintained.
Focal Hand Dystonia
Dystonia is a syndrome characterized by involuntary prolonged muscle contractions that can lead to sustained twisting postures.46-48 Three criteria are used in classifying this
syndrome: age of onset, cause, and distribution of symptoms.47,48 Onset before 28 years of age is classified as early,
and after this age is classified as late-onset dystonia. Cause
can be divided into primary/idiopathic (no obvious affects on
the brain) or secondary/symptomatic (often the basal ganglia
are affected, resulting in more generalized symptoms).46 Distribution of symptom manifestation can be
• General—symptoms manifest in all extremities including the trunk.
© K.Butler2009
Figure 142-9 Focal hand dystonia in musicians showing lack of motor
coordination or loss of voluntary control in a cellist’s (A) and pianist’s (B)
right small and ring fingers.
The estimated prevalence of FHD among professional
musicians is about 2% to 10%,54-56 which is higher than that
of writer’s cramp (0.1%) in the general population.57 FHD is
overwhelmingly more common in classical rather than pop,
rock, or jazz musicians. The high percentage of FHD in this
population reflects the specific demands of continuous repetition made by classical music.
© K.Butler2009
Figure 142-8 Task-specific action-induced focal hand dystonia has different forms, including musician’s dystonia that can affect the hand and
embouchure (A) and writer’s cramp (B).
• Hemi—symptoms are focused on one side of the body.
• Segmental—a segment of the body is affected.
• Focal—a single body part is affected.
Any part of the body can be affected by focal dystonia,
including the neck, eyelids, vocal cords, or hand.49,50
This following section focuses on focal hand dystonia, a late-onset, primary dystonia that is often task-specific
and includes musician’s and writer’s cramp (Fig. 142-8).
Focal Hand Dystonia in Musicians
FHD in musicians is a painless primary dystonia that tends to
be task-specific, focal, and of late onset. Symptoms can include
lack of coordination, cramping, and tremor51 and tend to be
specific to each individual and related to the instrument
played rather than hand dominance (Fig. 142-9).
Patients can respond to sensory tricks and, if they do, this
is usually a good indicator of how successful hand therapy
will be. Sensory tricks can be used to “fool” the brain and give
a “nonsense” feedback loop that breaks the fixed link in the
sensory motor loop for a short period.49,52,53 Often the novelty
is only effective for a short time until the brain recalibrates
to an automatic pattern, which is the dystonic one. Coban,
Blu-Tack, latex gloves, and orthoses can all be used as sensory
tricks (Fig. 142-10).
At present there is no cure for dystonia, and many of the
treatments available have significant limitations. Current
treatments include oral medication such as trihexyphenidyl,
botulinum toxin injections, surgery, rehabilitative therapies,
and supportive approaches. Butler and Rosenkranz9,58 published two papers that clearly outline many of the treatments
that have been researched and undergone clinical trials.
The rehabilitative approaches include
• Sensory
• Sensory–motor retuning (SMR)—combines both the
sensory and motor aspects of FHD.
• Multidisciplinary approach—includes hand therapy
and combines the sensory and motor aspects of FHD.
• Limb immobilization—interrupts motor performance
and decreases afferents from the limb.
• Supportive approaches—can include assistive devices,
instrument modification, Alexander technique, and
psychotherapy. There is a strong clinical impression
within a very experienced group of treating practitioners that some personality abnormalities and a strong
psychological trait is correlated with patients who
develop FHD.
The mechanisms by which FHD develops in musicians
need to be identified. Treatment must assist in reestablishing
sensory–motor control. A comprehensive therapy program
with an aggressive sensory reeducation element can improve
sensory processing and motor control of the hand. SMR is of
value for treating FHD in pianists and guitarists. Scientific
research investigating preventative measures and appropriate
treatments for FHD is essential. Collaboration and a multidisciplinary team approach to prevention, treatment, and
research are imperative and will be of benefit to all.
A fuller overview of current treatment principles can be
found in Butler and Rosenkranz.59
Work-Related Upper Limb
Disorders, “Overuse,” or
Nonspecific Arm Pain
The term overuse injury has been defined as a condition that
occurs when any biologic tissue is stressed beyond its physical or physiologic limits. The common presenting complaints
are pain and stiffness but may include swelling and diminished coordination and function. Some histologic studies
have revealed pathologic but nonspecific changes.60 There is
no clear evidence that musicians suffer true overuse with
tissue damage, as seen in athletes, and the experimental evidence used to argue this point in musicians is not strong.61
The clinician needs to be careful to assess the patient
thoroughly with respect to diagnosis and then to review for
nonspecific arm pains. The diagnosis of nonspecific arm pain
should not be seen as a blanket term for patients for whom
no specific diagnosis can be made.
Classification and Grading
Work-related upper limb disorders (WRULDs), overuse, or
nonspecific arm pain injuries can be classified as acute or
chronic. An acute injury follows a specific incident, such
as overpracticing a difficult passage. The musician may experience pain or stiffness during practice or the following day.
A chronic injury usually has a more insidious onset. The limb
becomes progressively more painful and dysfunctional over
Fry62 has developed a five-category grading system:
Grade 1. Pain at one site only while playing
Grade 2. Pain at multiple sites
Grade 3. Pain that persists well beyond the time that the
musician stops playing
Grade 4. All of the above plus activities of daily living
(ADL) begin to cause pain
Grade 5. All of the above plus all daily activities that
engage the affected body part cause pain
Most injuries fall into categories 1 to 3.63 The earlier the
symptoms are recognized and treated, the sooner the recovery is likely to occur and the more complete it is likely to be.
Unfortunately, the prevalence of injury can be quite high,
especially among professional orchestra members. A survey
of more than 2000 orchestra members revealed 76% of those
surveyed had significant physical problems.64 Subtle loss of
motor control or technique may be one of the earliest signs
of overuse.65
© K.Butler2009
Figure 142-10 A, B, Cellist utilizing latex glove as a sensory trick.
C, Dorsal blocking orthoses to limit hyperextension of the compensatory
finger, and in turn act as a sensory trick in patients with focal hand
Treatments for Nonspecific Arm Pain
The cornerstone of treatment is pain avoidance, also known
as relative rest.66 Other treatment modalities will usually be
inadequate unless relative rest is strictly observed. It is
important to emphasize to the musician that they must not
avoid playing altogether, but equally that they must not play
for long periods of time. The patient must become highly
aware of pain-producing activities, be they musical, nonvocational, or ADL. The patient must learn to avoid, or at least
modify, those activities to minimize the number of daily
painful “twinges.”
Hand therapists can assist in giving advice about joint
protection and energy conservation techniques. These principles are similar to those used for patients with rheumatoid
arthritis (Box 142-1).
Principles of joint protection and energy conservation can
be employed to preserve the patient’s joints and reduce pain
levels. It is a “style of life” that once learned becomes second
nature. It is not designed to make life complicated, but rather
to encourage independence. These principles are also very
important to implement if the patient is hypermobile.
All previous treatment methods mentioned in this chapter
apply to musicians who experience nonspecific arm pain.
The playing position, the interface or relationship between
the instrument and the musician’s body and vice versa, and
general levels of fatigue all need to be assessed and relevant
modifications made, as these all affect symptoms and healing.
Nerve Entrapment Syndromes
Digital Compression Neuropathies
Digital compression neuropathies occur when the digital
nerves are compressed between the hard instrument and the
phalanx. Many different instrumentalists can present with
these symptoms:
• percussionists, especially players of double-mallet
instruments, such as the xylophone, vibraphone, and
• the index fingers of those using traditional drumsticks
• the left index finger of flutists
• the right index finger of violin, viola, and cello players,
from pronation forces against the bow stick
• the right thumb tip in cellists where it presses against
the “frog”
Coban wrapped around the bow, stick, or the finger
works especially well to protect the digital nerve. The use of
a foam pad or Lycra or silicon sleeve such as Silipos can
also assist with proprioceptive retraining on the instrument
(Fig. 142-12).
It may be necessary, depending on the severity of the condition, to reduce playing time. Misdiagnosis is common, and
clinicians can often be misled by the presence of index
finger paresthesias into considering carpal tunnel syndrome.
Electrodiagnostic testing can be useful to clarify the diagnosis, especially with “double-crush” syndromes, in which
the patient may have multiple sites of entrapment,67 such as
the cervical, brachial, or carpal regions. This highlights the
importance of observing the musician playing the instrument.
Where practical and possible, musicians are always assessed
with their instrument, and frequently treatment sessions
involve the use of the instrument as a rehabilitative tool.
Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) can be classified as bona fide
and non-bona fide. Winspur68 wrote about three classification subgroups for musicians suffering from CTS.
• Classic idiopathic CTS, or bona fide CTS—caused by
increased pressure within the carpal tunnel.
• Wrist flexor tenosynovitis with carpal tunnel-like symptoms.69 These symptoms usually emerge following
intense practice or prolonged performance. The symptoms are not present when the musician has a break
from playing, is on holiday, or limits playing. Examination shows boggy swelling at the wrist, and the flexor
tendons are commonly swollen, nodular, and tender.
Nerve conduction studies (NCS) are normal, and
Phalen’s test produces discomfort but no paraesthesia.
Treatment for flexor tenosynovitis of the wrist is conservative and NSAIDs with or without an injection of
nonabsorbable steroid into the carpal canal can be of
great value. If NCS are abnormal, then surgery may be
indicated, but it should be considered as a last resort.70
• Acute positional CTS symptoms70,71 can be due to positioning the wrist in flexion while playing, and thus
symptoms may only occur during the act of making
music. In Figure 142-13 you can see the amount of
wrist flexion used by this guitarist to gain access to the
lower strings; sustaining this position can lead to carpal
tunnel-like symptoms and can in turn cause trauma to
the median nerve if the playing position and schedule
is not modified adequately.
Diabetes, thyroid disease, peripheral neuropathy, and
fluid retention associated with pregnancy can be predisposing factors. CTS symptoms may also be due to cervical
symptoms, and thus upper limb tension testing may be
necessary and appropriate to differentiate the source of the
Wrist orthoses can be useful for decreasing pressure on
the nerve and retraining wrist positioning while playing. The
orthosis should hold the wrist in a neutral position of 0 to 5
degrees extension. Most commercial orthoses hyperextend
the wrist considerably more than this, thus possibly raising
the pressure in the carpal tunnel. The palmar aluminum
strips can easily be flattened out to achieve a neutral position.
The orthoses should be worn at night for those who complain
of nocturnal or early morning paresthesias. If positional paresthesias occur during the day, the orthoses may be worn
then as well but should be removed hourly for gentle, active
ROM exercises to prevent stiffness. Depending on the severity of the symptoms it may be necessary to use a full-length
resting orthosis, since wrist orthoses leave the fingers free to
pinch and grip and this can lead to raised carpal tunnel
Musical technique should be evaluated to minimize
extremes of wrist position. Biofeedback may be used for
neuromuscular reeducation to reduce grip force and fingertip
loading. Orthoses can be useful for retraining wrist position.
For example guitarists can benefit from using a wrist orthosis
while playing to retrain a more neutral wrist position
and facilitate use of larger joints like the elbow or shoulder
(Fig. 142-14).
Box 142-1
Patient Handout on Joint Protection and Energy
Conservation Techniques
1. Use joints in a good position.
2. Avoid activities that do not allow for a change in
3. Respect pain.
4. Avoid tight grips or gripping for long periods,
especially small and narrow objects.
5. Avoid actions that may lead to joint deformity.
6. Use one large joint or many joints.
Joints work best in certain positions. When they are used
in the wrong position, such as twisting, extra force is
placed through the joint and the muscles are unable to
work as well, eventually causing pain and deformity.
When you are in a position for a long time your muscles
get stiff and pull the joint into a bad position. The
muscles also get tired quickly and so the force is taken
up by the joint and not the muscles, thereby leading to
pain and damage.
• Many items have been ergonomically designed and can
be purchased from many supermarkets and department
Some directions of force can be more detrimental than
others to the hand. Damage to your joints could lead to
deformities in your hand, such as your fingers appearing
to drift in the direction of your little finger (ulnar
deviation) or your individual fingers bending or
straightening in unusual positions (swan-neck
deformity). Activities can be changed to avoid these.
• When turning taps or opening and closing jars, use the
palm of your hand and use one hand to open and the
other to close. Remind others not to close them too
• Use a flat hand when possible such as when dusting or
• Try to use lightweight mugs with large handles rather
than small teacups so pressure is not put on just one
or two fingers.
The nature of arthritis means that you may always have
pain. If pain continues for hours after an activity has
stopped, this means that the activity was too much and
should have been changed or stopped sooner. Your
therapist will talk to you about the many ways of dealing
with pain, such as the use of orthoses, saving energy,
learning relaxation methods, planning the day ahead or
using equipment or gadgets to help you with certain
Stronger muscles protect large joints, so it is better to use
large joints when possible or try to spread the force over
many joints.
• Use the palms of your hands and not your fingers
when you carry plates or dishes.
• When standing up from a chair, try to rock gently
forward and use your leg muscles to stand up rather
than pushing from your knuckles or wrists.
• Carry light bags from a strap on your shoulder rather
than your hands.
• Use your bottom or hips to close drawers or move
light chairs.
• Use your forearms to take the weight of objects when
carrying, not your hands.
Gripping tightly increases your pain and may damage
your joints further. It is better to avoid it if possible. If
you grip something that is small or narrow it can require
greater power to hold and manipulate it. More power
usually means an increase in pain and an increase of
forces through the joints. Some examples of how to
decrease strain on joints include:
• Using thicker or padded pens for writing
• Resting books on a table or book rest
• Using a chopping board with spikes to secure
• Using nonslip mats under bowls to hold them
• Allowing hand washing to drip-dry rather than
wringing it out
• Relaxing your hands regularly during activities such as
knitting or writing
• Building up objects using foam tubing or using special
grip aids
• Increasing the grip ability on a slippery object such as
a shiny pen or toothbrush by using Elastoplast or
Coban tape
Balance rest and activity.
Organize and arrange space.
Stop activities or parts of them.
Reduce the amount of weight you take through your
5. Use equipment that saves energy.
It is important to balance your rest and activity to allow
your joints to rest and repair. Stop before you feel tired
or are in pain and avoid activities that you can’t stop
when you need to.
• Try to plan ahead. Write a weekly or daily diary with
activities in red and rest times in blue. Think about
what you need to do and space the harder activities
out over time.
Box 142-1 Patient Handout on Joint Protection and Energy
Conservation Techniques—cont’d
• Activities such as vacuuming, ironing, and cleaning
windows mean that you are dong the same movements
lots of times and keeping the hand in the same
position for long periods of time. Try to do them for
very short periods, or when possible get someone else
to do them for you.
Prepare your work areas so you have everything you
need for that activity. Store items you use often in places
that are easy to reach, and keep things in small refillable
containers, rather than large, heavy jars.
• Use clothes that are easy to care for.
• Make the bed on one side and then the other.
• Soak dishes before washing them and let them
• When possible use tinned, frozen, or prepared foods.
• Hang items within easy reach.
• When possible get someone else to help with
• Consider using wheeled trolleys rather than carrying
• Slide pans when possible, and use a wire basket or
slotted spoon to drain vegetables.
• When you buy new equipment, make sure it is
• Use a teapot or kettle tipper, and fill the kettle with a
lightweight jug.
Your therapist will discuss with you some of the things
that are available to buy.
Automatic washing machines, frost-free freezers, and
food processors are all energy-saving devices; and simple
things such as sharp knives use less pressure and,
therefore, less energy.
It is important to maintain the amount of movement you
have in your joints so that you are able to use your
hands as much as possible. You may find that without
regular exercise your hands feel weak and activities
become more difficult. Exercise can help to relieve pain,
keep bones and muscles strong, and keep your joints
moving. Strong muscles around your joints can help
keep them in a good position, but do not overdo your
exercises or use weights or resistance as this may harm
your joints.
Your therapist will talk to you about wearing an orthosis.
They can be used to rest a joint and allow the muscles
around it to relax. This can help reduce swelling and
pain. Orthoses can also be used to prevent deformities
around the joint or stop existing deformities from
worsening. It is often advisable to wear one during
activity to support a joint and restrict movement.
There are various types of orthosis and your therapist
may provide you with more than one.
A thermoplastic resting orthosis can be made, which
due to its strength can also be used during activity to
restrict movement around the joint. Softer orthoses made
from neoprene are also available that allow more
Other therapy tools that people have found useful are
Lycra gloves worn at night and hot or cold gel packs.
Your therapist will talk about your symptoms and your
daily activities (Fig. 142-11).
© Butler and Coldham, 2006.
Cubital Tunnel Syndrome
The boundaries of the cubital tunnel are the medial epicondyle anteriorly, the ulnohumeral ligament laterally, and the
fibrous arcade formed by the two heads of the flexor carpi
ulnaris (FCU) posteromedially.72 A fibrous band from the
olecranon to the medial epicondyle forms the roof of the
tunnel. The pertinent clinical biomechanical features are a
55% narrowing of the cubital tunnel, along with a marked
increased pressure, during elbow flexion.73,74 In vivo, additional pressure may be caused by FCU muscle contraction.31
The latter is evidenced by the high incidence of cubital tunnel
syndrome in the left hand of string players,74 in whom a
combination of elbow flexion and FCU contraction is found
(Fig. 142-15).
Piccolo players’ right and left arms and the left arm of
cellists are at high risk of developing cubital tunnel syndrome
because they are required to play with extreme elbow flexion
for extended periods.
The most common clinical findings are a positive Tinel’s
sign over the cubital tunnel. With the patient’s elbow fully
flexed and the wrist held in a neutral position, the examiner
taps over the nerve with her finger (not a reflex hammer). A
positive elbow flexion test can produce paraesthesia in the
ulnar aspect of the hand. The examiner should document in
the medical notes the length of time it takes for the symptoms
to appear as this is an objective marker and can assist in
evaluating symptom history and treatment effectiveness.
Weakness in the abductor digiti minimi is also a common
presenting feature in cubital tunnel syndrome.75
Although electrodiagnostic testing may be helpful in
evaluating the severity of the condition, it may be negative,
even in the face of florid symptoms.76 One must always treat
the patient, not the test.
© K.Butler2009
Figure 142-13 The extreme wrist flexion and finger abduction assumed
by some players to access the lower strings and play certain chords on
the instrument can cause acute positional carpal tunnel syndrome.
© K.Butler2009
Figure 142-11 Thermoplastic thumb metacarpophalangeal (MCP) joint
immobilization orthosis can be used as a form of joint protection and can
assist in “off loading” pressure on the carpometacarpophalangeal (CMC)
joint. A, lateral view. B, volar view.
The mainstay of treatment is prevention of sustained or
repetitive elbow flexion. A semirigid night orthosis is better
tolerated than a rigid one because it achieves better compliance. If night positioning alone is inadequate to control
symptoms, an adjustable, hinged elbow brace may need to
be used during the day. The hinge is adjusted to allow full
extension and up to about 45 degrees of elbow flexion (or
less, if 45 degrees still produces a positive elbow flexion test).
In extreme cases, an ulnar “gutter” may be added to the
orthosis to block abduction of the fifth finger. As the symptoms subside, the hinge is adjusted to allow progressively
increased amounts of elbow flexion (but never to the point
of paresthesia production). When 90 to 100 degrees of flexion
is attained without producing paresthesia, a “weaning-off”
schedule is instituted by removing the brace for 30 minutes
twice a day and progressing until the patient is off the
Return to playing the instrument must consider a gradual
resumption of elbow flexion and FCU contraction (see
section on Resuming Playing After an Injury). Oral medications such as NSAIDs or gabapentin may be very helpful.
Injection of soluble corticosteroids can be helpful but must
be done with caution to avoid intraneural injection.
Sometimes these patients require a surgical release, with or
without transposition depending on the surgical finding and
© K.Butler2009
Figure 142-12 A, Foam padding stuck onto the index finger and
thumb of an alto flute player to assist in retraining pressure being used
to hold the instrument, that is, increasing proprioceptive awareness and
in turn decreasing the amount of pressure placed through the finger and
thumb. B, Silipos digital sleeve can be useful in decreasing the pressure
exerted through a finger or thumb and in retraining positioning on the
© K.Butler2009
Figure 142-14 Utilizing a wrist orthosis to retrain wrist position and
encourage larger movements of the elbow and shoulder when accessing
the lower strings on a classical guitar.
Aspiration is commonly performed; however, there is a 50%
recurrence rate after this procedure.
A more effective method is to rupture the ganglion. The
clinician fills a 10-mL syringe with a mixture of half sterile
water and half 2% lidocaine. The skin is anesthetized by
using Fluori-methane spray. Using an 18-gauge needle, lidocaine is injected until the ganglion ruptures. This may require
quite a bit of force. The thick viscous gel spreads subcutaneously over the dorsum of the hand and is reabsorbed in a few
days. A compression dressing with sterile gauze and Coban
should be applied and left in place for a day or two. Wrist
active ROM exercises should be commenced as soon as
possible following this procedure in order to minimize any
decrease in range.
General Treatment Principles
for the Musician
© K.Butler2009
Figure 142-15 A combination of elbow flexion and flexor carpi ulnaris
contraction in the left upper limb of a viola player can lead to cubital
tunnel symptoms.
the playing position. Following surgery, instrument-focused
rehabilitation is imperative.
Radial Nerve Neuropathies
Although uncommon, sensory radial neuropathy should be
mentioned in passing because it is often mistaken for de
Quervain’s disease or nonspecific arm pain. Patients suffering
from this neuropathy may display a positive Finkelstein’s
test, paresthesias over the dorsum of the radial side of the
hand, and have a Tinel’s sign over the radial aspect of the
forearm where the nerve emerges between the tendons of
the extensor carpi radialis longus and brachioradialis. When
the forearm is pronated, these tendons “scissor” the nerve
between them.78 As the terminal branches go to the dorsum
of the thumb, ulnar deviation with thumb adduction stretches
the already compromised nerve. This combination of forearm
pronation, ulnar deviation, and thumb adduction occurs with
upbowing as the bowhand approaches the strings. During
practice the bowstroke can be limited to minimize the
offending position. Tight watchbands may contribute to the
problem and the bands should be loosened or the watch
Standard therapeutic modalities such as ice, compression,
electrotherapy, orthotic positioning, exercise, sensory reeducation, postural reeducation, acupuncture, environmental
assessment, examination of technique, holistic approach,
breathing, myofascial release, and nerve glides can be useful
when treating musicians; however, when possible the instrument should be used as the therapeutic tool.
Instrument-specific rehabilitation techniques such as the
use of surface electromyographic biofeedback while the
patient is playing the instrument can help detect the presence
of excessive muscular activity80,81 in the forearm flexors,
extensors, or trapezius muscles. Levy and colleagues82
carried out electrical studies on biceps, deltoid, trapezius,
and sternomastoid muscles of violinists while they played
two sections of music. As the musician’s neck dimensions
increased, the shoulder rest was more likely to promote
diminished electrical activity from the tested muscles, and
thus the investigators demonstrated that the shoulder rest
had a great effect on muscles used to support the violin and
that with proper rest musculoskeletal injuries might be
Video feedback may be used to increase awareness of
posture and technique and is complementary to biofeedback.
In video feedback, the patient faces a video monitor and plays
his instrument while the therapist gives postural cues.12 The
video camera is placed at various angles, allowing the musician to see his posture from several perspectives. The camera
can record the session for further study and review. Where
possible the patient is assessed on and off the instrument, as
sometimes their difficulty will only become evident when
they are in the playing position or demonstrating playing.
Orthotic Intervention
Scapholunate wrist ganglions are the most common type and
do not usually require surgical treatment. However, they
can be symptomatic when stretching periarticular tissues,
especially with instruments that require extremes of wrist
flexion or extension.79 Surgery should be a last resort because
there is a risk of leaving the patient with decreased ROM.
Various types of orthoses are available, and it may be appropriate for the patient to have more than one during the day
depending on the activity being performed.
Functional Thumb Metacarpophalangeal Joint
Extension Blocking Orthosis
Hyperextension of the first MCP joint is commonly observed
in people with hypermobility and arthritis and in
© K.Butler2009
Figure 142-16 Functional thumb metacarpal extension blocking orthosis can be used to block hyperextension of the metacarpophalangeal (MCP)
joint while still allowing full flexion of the carpometacarpal, MCP, and interphalangeal joints. This orthosis can be utilized in many functional tasks such
as playing a musical instrument or writing.85
professionals such as musicians2 and hand therapists.83 This
may be due to decreased stability of the first carpometacarpal
(CMC) joint or MCP joint,84 which subsequently leads to
degenerative changes. Butler and Svens85 present an alternative orthosis based on Van Lede’s86 anti-swan-neck orthosis
for fingers, which restricts MCP joint extension of the thumb
(Fig. 142-16). This orthosis can be very useful for retraining
awareness of joint positioning on the instrument and while
writing. It can decrease joint strain and in time assist in
increasing the strength of the muscles surrounding the joint
and thus aid joint stability.
Osteoarthritis and the Thumb
Carpometacarpal Joint
A thermoplastic resting orthosis can restrict joint movement
while functional tasks are being performed. This orthosis can
also be worn while sleeping (Fig. 142-17). Softer orthoses
made from neoprene allow more movement and provide
© K.Butler2009
Figure 142-17 Thermoplastic thumb metacarpophalangeal joint immobilization orthosis.
© K.Butler2009
Figure 142-18 A-D, An Orfit metacarpophalangeal joint blocking
orthosis and Velfoam thumb abduction strap can assist in allowing a
gentle return-to-play schedule.
© K.Butler2009
Figure 142-19 Neoprene orthoses without (A-C) and with (D) thermoplastic reinforcement.
some warmth to the affected area. Other therapy tools that
osteoarthritis patients can find useful are Lycra compression
gloves worn at night and hot or cold gel packs.
(Fig. 142-20). Figure 142-21 shows a dynamic MCP joint
extension orthosis with radial pull that a pianist used during
the daytime while performing functional tasks as well as in
a graded return-to-play program. She was supplied with a
resting orthosis with an ulnar border build-up to wear at
night. This patient had a 35-year history of rheumatoid
arthritis and she was finding playing increasingly difficult. A
crossed intrinsic transfer with synovectomy was performed
and she commenced light playing after 4 days of surgery,
with the orthosis on. She commented: “I have been amazed
with the results, as I have not been able to play like this for
20 years. I did not think this improvement was possible. My
finger is articulating in a crisp way. My husband can hear the
difference already as well.” Getting the patient back on the
instrument as soon as is reasonably possible and anatomically
safe is integral to the whole healing of a musician.
Functional Orthoses
Following an ulnar nerve injury, hyperextension at the MCP
joints and an adducted thumb can render the hand fairly
dysfunctional. With careful orthotic positioning, ADL’s and
a graded return-to-play program can commence (Fig. 14218). Prefabricated wrist orthoses can be used to retrain wrist
position while on the instrument (see Fig. 142-14). Neoprene
orthoses can be worn to support a joint or area and limit
some movement, while increasing proprioceptive awareness
and warmth. A thermoplastic reinforcement can be added to
increase support or further limit movement (Fig. 142-19).
These orthoses can be a useful way for a musician to gradually progress from a wrist orthosis to a neoprene orthosis to
no orthosis.
Dynamic Orthoses
Injury may result in a lack of full ROM. This can limit the
possibility of certain positions on the instrument. Following
surgery certain structures may need protection while they
heal. If the therapist wants to promote gentle motion, then
dynamic positioning is often the most appropriate means
Musical Ergonomics
Musical Instrument Modifications
Guitars and, recently, violas have been designed with part of
the body of the instrument recessed to permit the use of a
more neutral wrist and more optimal ergonomic position
Figure 142-22 The Erderz viola modification allows easier access of the
left hand to higher positions, with minimal wrist flexion.
© K.Butler2009
Figure 142-20 A, Dynamic proximal interphalangeal joint flexion
orthosis. B–D, Dynamic composite proximal and distal interphalangeal
joint flexion orthosis.
when playing and accessing the higher positions with the left
hand (Fig. 142-22).87 The resultant decrease in left wrist
flexion can help avoid the high pressures associated with
CTS and minimize friction of the flexor tendons against
the transverse carpal ligament. Some electric guitars and
violins finesse this problem altogether by virtually eliminating the body of the instrument.
The lower “bout” of the acoustic guitar (the part where
the right forearm crosses the instrument) also can present
a physical obstacle (Fig. 142-23A),87 resulting in either
excessive right wrist flexion or protraction of the right
shoulder for the right hand to access the strings. The
larger the body size of the guitar or the smaller the player,
the bigger the problem. Laskin88 has developed a small
beveled edge for the classical guitar where the right
forearm crosses the instrument. This idea was further developed by Norris and Dommerholt87 to a more radical bevel,
improving right-hand access to the strings with minimal
distortion of right shoulder and wrist position (Fig.
For the soloist or short double bass player, the instrument
should be selected with sloping shoulders if one does a lot
of playing in the high positions (e.g., soloists). This minimizes impingement of the left forearm against the sharp
edge of the instrument or thrusting the left shoulder
forward to avoid forearm impingement when reaching down
the neck.
The bassoon can be designed and made with levers and
extended keys to decrease an excessive span of the fingers
and thus prevent development of an intrinsic muscle strain.
Reduction of Static Loading
© K.Butler2009
Figure 142-21 Dynamic metacarpophalangeal joint extension orthosis
with radial pull that a pianist used 4 days after cross intrinsic transfer with
Static loading, which occurs when the weight of a tool is
sustained and supported by the hand, has long been recognized as an etiologic factor in workers’ injuries. Industry has
addressed this by developing ways to suspend tools to remove
the weight from the hand.89 This approach has also worked
for musical instruments. Adding an end pin to the cello
Figure 142-23 A, The lower bout of the acoustic guitar presents a mechanical obstacle to optimal right shoulder, arm, and wrist position. B, Norris’
design for a beveled lower bout.
relieved the player from supporting the instrument by grasping it with the legs. End pins have also been successfully
employed in the bassoon, English horn, and tuba. The end
pin for the last two instruments has been modified into a ball
that rests on the chair between the thighs.
Several devices available on the market relieve the right
thumb strain so common to oboe and clarinet players.90,91
Freeing the right hand also allows alternative fingerings that
may be more efficacious. The Weightlifter (Robert James
Products, San Marcos, California) is a tripod support upon
which the bell of the instrument rests. It can be used whether
the musician is seated or standing. It is relatively heavy,
making it somewhat impractical for travel. The FHRED
(Quodlibet, Englewood, Colorado) is a lightweight, heightadjustable post that attaches to the thumb rest and rests on
the seat between the player’s legs. It can be used only while
seated. A small support can be applied to the body of the
flute to take the strain off the left index finger and to remind
the player not to press this finger into the instrument (see
Fig. 142-4C).
The bassoon is most commonly supported by a seat
strap that is attached to the end of the instrument. This still
leaves quite a bit of weight to be supported by the left
hand due to the leftward inclination of the instrument.
There is also torque on the left hand because it must counteract the tendency of the instrument to roll outward.
Some bassoonists prefer a body harness onto which the
instrument clips.
Key Modifications
Many instruments can be modified to make playing them
more comfortable and safer.
The levers that operate the valves on the French horn can
be lengthened to provide greater leverage and widened to
provide increased contact area.
A hooklike device can be soldered onto the upright post
of a trombone, significantly decreasing the stretch required
for the left index finger to support the mouthpiece. The post
itself can be wrapped with Coban to prevent digital nerve
compression (Fig. 142-24).
The location of the flute keys can be customized (Lunn
Flutes, Newport, New Hampshire) to fit the players’ hand,
and the cluster of keys worked by the right little finger can
be angled in toward the finger, thereby reducing strain
between the fourth and fifth fingers. The keys operated by
the left fourth and fifth fingers can be lengthened to achieve
a more neutral left wrist position. A flute with a U head can
be useful for children, or covering the open holes of a flute
following injury to the hand can facilitate ease of return to
play, and in time the keys can be “unblocked” and open holes
can be used again as the patient recovers and gains confidence. In addition to these modifications, children can benefit
from disks being soldered to the keys for the right index,
middle, and ring fingers to reduce the distance between keys,
thus reducing hand strain.
Although left-hand problems outnumber right-hand problems in flutists, quite a few players have suffered from strain
Figure 142-24 A, The left hand of this young female trombonist shows strain between the index and long finger, and digital compression of the
radial aspect of the long finger against the upright post. B, Norris’ modification, adding a hook under the mouthpiece, and padding the upright. Note
that the thumb key has also been modified for improved interface. C, These modifications decrease interdigital strain and protect the digital nerves.
Figure 142-26 A, Guitar pick affixed to end of prosthesis. B, Adaptive
device for holding trombone.
Figure 142-25 The flautist’s right thumb “rest” stabilizes the instrument
and enhances right thumb comfort by better distributing the pressure.
This, in turn, allows a neutral, as opposed to a supinated, thumb
and physical tension in the base of the right thumb and the
muscles pertaining to this area.92 One could argue that this
most likely represents an error of technique, with the person
using an excessive amount of tension in the right hand or
incorrect placement of the right thumb. However, certain
intrinsic balance problems with the instrument benefit from
the enhanced stability attained with the use of orthoses or
Discomfort may arise from the very small area of contact
between the edge of the right thumb and the flute when the
hand is held in the “natural” position, with the ulnar edge of
the thumb facing the pad of the index finger. This is the
position the thumb falls into when the hand is relaxed. This
position concentrates the force from the flute over a small
bony area of the thumb, which does not have a very high
pressure tolerance. The common solution to this problem is
to supinate the thumb so that the soft pad contacts the flute.
Achieving and maintaining this position requires muscular
force. Increased muscular tension in the thumb and hand
may not only cause pain and injury but also may inhibit
The flute rest uses a nonslip, cork-lined metal clip that
grips the flute and has an adjustable, foam-padded metal
extension customized to fit the thumb (Fig. 142-25). This
device serves two main purposes: it distributes pressure from
the flute over a wider area of the thumb, thus allowing the
thumb to be comfortably held in the natural position, and it
encourages stability by positioning the weight of the rods to
fall through the base of support, thus preventing the flute
from rolling inward.93
Adaptive Equipment for
the Physically Disabled
Musical instruments can be modified or adapted to increase
the ease of playing them, if the individual has a physical or
mental disability. French horns, normally played with the left
hand, have been built to accommodate left upper extremity
amputees. Adaptive prosthetic terminal devices have been
fabricated94 to allow holding of the trombone, and
drumsticks and metal picks have been affixed to the end of
the prosthesis to allow guitar playing (Fig. 142-26).
For quadriplegics and people with severe neurologic
impairments, sip and puff controls can be adapted to the
computer and used in conjunction with one of a number
of musical software packages to allow composition and
Resuming Playing After
an Injury
The treatment of musicians’ injuries has two distinct phases.
Reducing pain or symptoms is the first stage. The second
consists of a structured protocol for returning to full musical
activity. If the player has had to stop or significantly reduce
playing during the pain reduction phase, a structured protocol for return to play is essential to decrease the chances of
repeated relapses. In this protocol, the musicians perform
their specific tasks, but start out at a greatly reduced level of
time and intensity. Injured musicians are often anxious about
being away from their instrument, and miss playing so much
that they return to playing prematurely and suffer disastrous
consequences. Fry(1986) quotes Poore(1887) on this95:
“The most important point in treatment is rest. The excessive use of the hand must be discontinued, and it is often
necessary to insist on this rather forcibly. Piano playing, if
not prohibited altogether, must only be practiced to a degree
short of that which causes pain or annoyance. It is often difficult to restrain the ardor of these patients in the matter of
playing. Directly they feel in a small degree better, they fly
to the piano; and I have known the progress of more than
one case very seriously retarded by the undoing, as it were,
of the good effect of rest by an hour’s injudicious and prohibited practicing.”
It is critical that the treating clinical team be fully educated
in both the psychological and practical aspects of guiding
their patients through the difficult and often treacherous
stages of resuming full musical activities so as to avoid the
despair that can accompany setbacks, treatment failure, or
career abandonment. Musicians should be reassured that
they are not going to lose their technique during the course
of a few weeks’ rest and that they can put their “time out” to
good use by working on music theory, harmony, sightreading, solfège, mental practice, silent practice, critical
listening to recordings, or learning something about the business aspects of music and career promotion.
The musical patient usually resists the recommendation
to completely refrain from the instrument and, fortunately,
this is necessary only in extreme cases. Usually it is sufficient
to reduce the intensity or time of playing, select a less taxing
repertoire, or take more frequent breaks. It may be necessary,
however, to cancel or postpone performance commitments,
exams, or auditions.
If one hand is injured, the player can sometimes continue
to do some playing with the unaffected side.
It isn’t necessary to be completely asymptomatic before
beginning the return-to-play program. A person who is not
yet ready or able to deal with the physical instrument can go
through the motions of playing without the instrument, what
Menuhin referred to as “shadow playing.”96 It is preferable
that the recovering player have the endurance to shadowplay comfortably for 10 minutes or so before beginning to
play the actual instrument.
The Return-to-Play Schedule
When the person is ready to return to the instrument, a
detailed return-to-play schedule is reviewed. It is inadequate
for the clinician merely to advise the player who is ready to
return to playing to “go back little by little.” This is too vague
and open to misinterpretation. The value of a written schedule is that it minimizes the risk of overdoing things. Even if
they believe that they can do more, players must be advised
to strictly adhere to the schedule. The use of a clock or timer
is more than helpful: it is critical, because the patient often
fails to recognize overexertion during the musical activity.
The pain can often evolve only hours later.
Depending on the severity of the injury or the length of
time taken away from the instrument, the musician may
begin cautiously with a single 2- to 3-minute period, or even
less, and see how they feel later that day and the next day. It
may be necessary to grade the return to play even more and
to instigate miming or performing the movements required
to play the instrument without even holding the instrument.
For example, a violinist may move their left arm up into the
playing position three or four times an hour each hour during
the waking day, to rehabilitate and “remind” the body about
the playing position. Shadow playing can be the next stage
in a graded return-to-play program. In this, for example, the
violinist moves their fingers over the strings but does not
depress the strings onto the violin. In time, light pressure
may be applied to the strings, and then half pressure, full
pressure, gentle vibrato, and in time full vibrato. Grading of
positions played and strings played on stringed instruments
can also be a way of increasing the difficulty and technical
requirements for the playing position.
To return the musician back to their pre-injury performance level can take a long time. The graded return-to-play
program provides an outline for how to achieve this. A gentle
encouraging approach by the treating medical professional is
often necessary to keep the musician in good spirits and to
facilitate a gentle pace of return to play. If the musician
rushes their return to play, he can in turn cause an increase
in symptoms and may require reverting to a lower level of
A brief physical warm-up and cool-down should precede
and follow playing, and if there is still some pain or discomfort, the sore part may be iced for 10 minutes or so after the
playing session. It must be emphasized that the ice is not
directly placed on the skin, but rather in a moist cloth or
using a purchased cold pack that is kept in the refrigerator.
The return-to-play schedule can and should be modified
to suit the individual player. In addition to the warm-up and
cool-down, the musician should begin with slow, easy pieces
or études. A metronome at a medium setting may be used,
and gradually tempos can be increaed notch by notch every
few days. The musician should also gradually work down
toward slower tempos, since the control required to play
slowly can be very demanding as well. With time, the player
gradually resumes more technically difficult material. Thus
the progression is really in three dimensions: gradually
increasing duration, tempo, and technical difficulty of the
The schedule (Table 142-1)66 is divided into play and rest
periods. Each level represents a unit of time, usually from 3
to 7 days, although this can be adjusted to meet individual
Table 142-1 Returning to Play
Levels (3–7 days at each)
• Start with slow and easy activity or pieces. Gradually progress to faster, more difficult tasks or pieces.
• In general, perform a maximum of 50 minutes continuous work or play with a minimum of 10 minutes rest.
• Warm up before playing!
• If pain occurs at any level, drop back to level of comfort until able to progress without pain.
From Norris RN. Musician’s Survival Manual, St Louis: ICSOM, 1993.
Box 142-2
Healthy Practice Habits for Musicians
You can correct a problem without sacrificing
• Take the first sign of an injury seriously; it may not be
necessary to completely stop playing.
• Practice only as long as you can maintain
• Take a 5-minute break every 20 minutes (e.g., water or
stretch breaks) so your muscles are more responsive.
adhering to a short fitness regime prior to playing.
• Warm up AT THE INSTRUMENT with easy music
concentrating on slow perfection to find easy postures
and positions (e.g., relax thumb if tense).
• Stretches and icing overworked areas of the body may
be necessary.
• Adjust seat and music stand for optimal posture.
• Keep wrists and thumbs in the neutral position as
much as possible by using forearm rotation.
• Good posture on stage communicates COMMAND and
needs. The musician should be comfortable at a given level
before progressing to the next level. The play periods gradually increase with each level, and the rest periods gradually
decrease. However, the play periods do not increase beyond
about 50 minutes, and the rest periods do not fall below 5 to
10 minutes. If the injury has been severe, the musician would
probably progress even more slowly.
If pain reappears after progressing to the next level, the
player should drop back one or two levels until the symptoms
subside. If absolutely necessary, the player may need to stop
for a day or two before resuming playing. If they encounter
difficulty progressing, it may be necessary to do a miniprogression, changing only one vertical column every 3 to 4 days.
For example, if the musician is at level four, rather than
increasing all the play and rest periods at a single time to level
five, an alternative would be to increase only the first play
period to level five, leaving the remainder of the play and rest
periods at level four. After a few more days, the second play
period is increased, then the second rest period decreased,
and so forth. In this fashion, the player may be able to make
steady, albeit slow, progress and this in turn will hopefully
assist in avoiding or decreasing levels of discouragement and
depression. In the sample program, level 10 represents about
4 hours of playing time. A performer who requires more than
• Often the technical solution to a problem is also its
musical solution.
• Extreme fatigue can indicate something is wrong
technically (e.g., inappropriate fingering).
• Volume and resonance can be produced with muscle
release and by using gravity.
• Neck straps, floor stands, customized chin rests,
individualized thumb stops or keys, instrument posts,
backpack-style carrying cases, or wheels on instrument
cases are available to minimize extraneous loading.
• Strive to REDUCE practice time prior to a performance
and increase mental training.
• Score read AWAY from the instrument to analyze and
memorize the music out of the habitual posture.
• Use visualization to hear and see your performance.98
• Balance relaxation with fitness activities that minimize
the risk of injury and help to alleviate your particular
muscle imbalances (professional advice may be
• A strong flexible muscle resists strain better than a
strong inflexible muscle.
this would simply keep adding more play and rest periods, as
shown, until achieving the desired goal.
To assist in decreasing the disruption in the flow of
practice, the musician can record the practice session and
critically review what she has just practiced during the
break periods.
A “Healthy Practice Habits” handout (Box 142-2)45 can be
helpful when reintroducing patients to their instrument after
an injury or indeed, time away for any reason. This can also
be used as an educational tool to assist in preventing injuries
and as a way of mapping progress. Sometimes a clock may
be utilized so the musician can time practice sessions carefully and not overdo it by accident. After a period of
not playing musicians must return with a slow graded
progression—in duration, tempo, and complexity of playing,
and they may require psychological support.97
Rehabilitation Protocols
To provide care on a sophisticated level, it is necessary to
modify the concept of return to play to address specific injuries and instruments. Here are a few examples of the principle
of instrument-specific return-to-play protocols:
A harpist with left shoulder strain initially avoids passages
with low notes. This is because the left shoulder has to flex
forward and protract to reach the lower bass strings, thus
placing increased strain on the anterior deltoid.
Piccolo players recovering from cubital tunnel syndrome
should commence practicing on the flute because the elbows
are more extended on this instrument.
String Players
A cellist or bassist with a left shoulder strain is recommended
to commence their graded return-to-play program primarily
with thumb position (down toward the bridge), where the
deltoid is more relaxed than in the first position (up by the
tuning pegs), which requires shoulder abduction. Because
the thumb position requires less elbow flexion, it is also advisable for a cellist recovering from cubital tunnel syndrome.
String players with de Quervain’s tenovaginitis of the right
wrist should avoid using the proximal third of the bow,
playing at the heel, because the wrist assumes an increased
flexed and ulnar-deviated position as the hand approaches
the strings on the upbow.
A cellist with right rotator cuff injury should initially
avoid bowing out to the tip of the bow, especially on the two
treble strings,99 to avoid abduction and internal rotation,
which aggravates impingement of the cuff. A violinist or
violist with the same problem, on the other hand, begins
on the two treble strings because reaching for the lower
strings with the bow necessitates humeral abduction, often
above shoulder height, which can aggravate rotator cuff
Guitarists with left hand or shoulder problems could place a
capo (a rubber-coated steel bar that clamps across the strings)
on the third fret, thus decreasing the stress of supination with
external rotation that occurs when playing on the first three
frets. Because the distance between the frets decreases as one
goes higher up the neck, the finger abduction required for
chords or intervals is also lessened. Guitarists can change to
lighter-gauge strings as a way of grading their return-to-play
A pianist recovering from a hand or shoulder problem might
avoid using the thumb on the black keys or crossing to the
opposite side of the keyboard to avoid wrist ulnar deviation
and shoulder adduction. It may be easier for the pianist with
painful forearm overuse to resume playing on a synthesizer
or electronic keyboard because the key depression requires
less force.
Surgery on musicians must be entered into cautiously—
either all other treatment options should have been attempted
first, or surgery must be the only appropriate treatment indicated. Importantly, the interface must be assessed and altered
as necessary, prior to surgery, for most conditions. Surgery
is often seen as the last treatment option available to a
Winspur100 reports that of the musicians presenting with
recognizable orthopedic or rheumatologic conditions in the
upper limb 4% to 6% are candidates for surgery. Nonsurgical
treatment should always be tried first, and it should not be
forgotten that in some situations adjustment or modification
of the instrument or playing technique (the interface) may
solve the problem rather than surgery.
The implications of surgery are profound for musicians,
whose hands are their livelihood. Thus respect for their hand
and career must be paramount. Accurate diagnosis, analysis
of need and disability, and precision in planning all need to
be carefully considered to ensure optimal outcome of surgery.
In the area of acute trauma, techniques that permit early
return to function (e.g., rigid fixation of fractures and early
rehabilitation) are often advantageous. Electrodiagnostically
documented carpal or cubital tunnel syndrome and ligamentous injuries leading to instability that have not responded
to activity modification or nonoperative therapy can be
considered appropriate indications for surgery in the musician’s hand.101
Winspur102 states that four areas must be identified and
specifically addressed when planning surgery on a musician’s
1. The incisions must avoid critical tactile areas.
2. Repair should be anatomic whenever possible.
3. Adjustment must be considered for any anticipated
anatomic compromise to the musician’s specific
musical needs.
4. The surgery should allow for an early return to limited
A large series of professional musicians operated on by a
single surgeon are presented by Butler and Winspur.103 These
are the results from that study:
• 127/130 musicians operated on returned to full-time
professional work or were able to complete their finalyear music college examinations.
• Piano players appear to take the longest to initially
return to their instrument (3.3 weeks) and string players
appear to take the most time to fully rehabilitate (11
weeks), that is to return to full playing on their
• Trauma appears to be the most difficult condition
from which to initially recover, with patients taking
an average of 5.2 weeks to return to part-time
• Full return to play took the nerve-release group an
average of 17 weeks, the arthrodesis and arthroplasty
groups 13 weeks, and the trauma group 12.7 weeks.
• The most common medical condition requiring surgery
in the series was nerve compressions (32.3%).
• Of the musicians undergoing hand surgery, 35.4%
played the piano or organ as their primary
For three patients the surgery was deemed unsuccessful:
• One was misdiagnosed with CTS, despite abnormal
NCS. This patient had multilevel cervical disk disease
and required spinal surgery. This patient was able to
return to teaching but not performing at a professional
level, after spinal surgery.
• One young pianist had a hypermobile thumb and was
lost to follow up. Early surgical results appeared to be
unsatisfactory following a synovectomy.
• One patient with a hypermobile distal radial ulnar joint
did not return to full-time professional performance
levels and now only does some teaching, due to a recurrent dislocating extensor carpi ulnaris.
These important points must be considered when working
with musicians who may require surgical intervention:
• All other treatment options must be attempted first.
• Surgery must only be considered when the condition
interferes with playing.
• Surgery must be strongly indicated, and the pros and
cons of the surgery must be discussed clearly with each
patient in respect to lifestyle, level of performance, and
the demands of the instrument.
• A specialized, multidisciplinary, and instrumentfocused approach is absolutely necessary when rehabilitating musicians.45
The following conclusions can be drawn from this large
series of 130 professional musicians, all of whom were operated on by a single surgeon:
• The musical instrument must be utilized as the rehabilitative tool, for the player to gain confidence levels,
ROM, desensitization, strength, and psychological
support during the rehabilitation phase, and thus strong
surgical techniques that can withstand early return to
play must be implemented when appropriate and
• Do not operate on hypermobile painful joints, but rather
utilize other therapeutic devices, such as positional
orthoses, to assist this patient group.
• Appropriate surgical intervention will not end a musician’s career, provided it is performed properly, for the
correct reasons, and with postoperative instrumentfocused hand therapy available.
There has been an increase in focus on health issues that
relate to performing artists in recent years. There is frequently hand and arm pain in this patient group. Their
playing conditions and lifestyles are often not conducive to
ergonomically sound approaches to performance and general
living standards can vary greatly. Rapid repeated movements
are often required, and frequently unusual postures are held
for extended periods of time. Overuse whilst playing, practicing, and performing is common in music students and experienced performers alike. Musicians are often perfectionists
who are striving for excellence in their field, and they are
usually ill-prepared for the physical and emotional demands
that may be placed on them in their student and professional
lives. When assessing and treating this group, early assessment and accurate diagnosis are imperative. Happily, surgical
intervention is not usually required and holistic approaches
to practice schedules, an ergonomic approach to playing, and
relevant warm-up and cool-down exercises can assist the
musician’s return to playing with much less pain or discomfort. Where possible, the musical instrument should be
utilized as a rehabilitative tool. A specialized multidisciplinary approach to rehabilitation is advantageous and necessary when working with musicians. Prevention of injury is
the primary aim of performing arts medicine. Scientific
research and practical advice regarding minimizing the
affects of performance and playing on the musician’s bodies
must be our focus, as well as educating the wider community
about these strategies. In this way, we can all enjoy a wide
variety of music and musical expression and the performers
can enjoy the experience of playing their instrument and
sharing music with the audience, with minimal tension and
pain in their bodies.
The complete reference list is available online at www.expertconsult.
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF