To get the most out of the following information, reading the three previous posts will give you the background information on this subject.
The information here is not a substitute for medical diagnosis and treatment.
Musicans’ hand discomfort or injury most often develops from holding the hands stiffly or awkwardly while plucking or pressing the strings or keys of an instrument. This can affect the muscles, tendons, tendon sheaths, joints, nerves and nerve sheaths of your hands, fingers and wrists.
Although these are often referred to as “repetitive motion injuries”, repetitive motion alone isn’t necessarily a problem, but repetitive motion under stress causes many injuries. “Stress” means any stiffness or tension of the muscles being used.
Many people think their hands are not agile when in fact they are just using them badly. You may not necessarily be aware when your hand is tense or your position is awkward. If you can’t feel it, you can probably hear it; tension in the hand makes the music sound tense and choppy.
To feel the difference between relaxed repetitive motion and stressed repetitive motion, try this experiment:
1. Away from your instrument, hold your hand parallel to the floor, palm down.
2. Let your fingers relax completely.
3. In this relaxed position, wiggle your fingers. This should feel very easy.
4. Next, bend the wrist so the hand is up as though you were stopping traffic, and wiggle the fingers again. Notice how they move reluctantly at best. One cannot expect to play well with the wrist bent in that direction.
5. Now, splay the fingers (fan them out as far as you can) and wiggle the fingers again. Stiff, eh?
Splaying the fingers or bending the wrist (in the direction described) requires significant flexion of muscles and related tendons, and this can potentially cause injury when in combination with the repetitive motion required to play an instrument. (There are also other ways one might tense the hand muscles, such as clenching the fist, but the above are mentioned because they are the most common for musicians.)
When we move our fingers, the tendons and muscles responsible are not just in the fingers. Finger movement is governed by tendons that begin at the fingers but extend through the hand and wrist, and attach to corresponding muscles in the forearm; therefore, finger movement actually originates in the forearm. There is one muscle for each finger on the outer side of the forearm, and another on the inside of the forearm. The ones on the outer side are responsible for upward finger movement and for opening the fingers, while the muscles on the inside of the forearm are responsible for inward finger movement and closing the fingers. Therefore we have to be careful with our arms as well as our hands. (See the arm illustration in my post of 6/27.)
By the way, wrist bones (carpals) have small spaces between them that close when you bend the wrist back. But when you straighten the wrist, those bones are more separated. Playing with a straight wrist creates less friction between the carpal bones.
Now try this:
- Hold your arm out with the wrist straight and the palm facing the floor. Let the fingers curl naturally. Now lift the curled index finger. Note how the associated tendon becomes prominent on the back of your hand. (Every time you lift a finger, you tense a tendon).
- Move the curled index finger into the palm of the hand. Notice how little the tendon moves by comparison. Into the palm is a relaxed plucking motion. Yet many string musicians pluck by lifting the fingers instead, which is awkward and tense.
Be aware of what you do with your hands in your everyday activities, too. If you use tools or work with your hands in any way, be careful about repetitive motion under stress. Typists, for instance, have a high rate of Carpal Tunnel Syndrome. Carpenters and gardeners are prone to tendonitis. If you talk on the phone for more than about 30 minutes a day, holding the phone to your ear can eventually injure the hand or wrist. (No kidding. Your neck can develop problems, too. Get a headset for your phone, or use the speaker function, to free your hands.)
Another factor in keeping your hands and wrists healthy: how do you hold your hands when they are not in use? Do you drum your fingers on tables or other surfaces, do you fidget, or do you clench your fists? Those subconscious habits can be noticed and changed.
What are the specific causes and symptoms of each of the common repetitive-motion-under-stress-injuries: Carpal Tunnel Syndrome, Tendonitis, Focal Dystonia and Tenosynovitis?
Carpal Tunnel Syndrome is a term that has been over-used and over-diagnosed. It’s a common injury, but be aware that there are other injuries that can produce similar symptoms, and which need to be treated differently.
Carpal Tunnel Syndrome occurs when the median nerve is entrapped where it goes through the wrist area, by inflammation (swelling) of its sheath or by a buildup of mucopolysaccharides (fatty deposits which can occur even if you’re not overweight) inside the sheath. One of the symptoms of carpal tunnel syndrome is sharp pain that shoots up the arm, which is often worse at night.
Tendonitis is an inflamed tendon. It can be exacerbated by excess mucopolysaccharides in the lubricating fluid (synovial fluid) around the tendon. Its symptoms include pain when the tendon is used, and sometimes swelling and/or redness in the affected area.
Tenosynovitis in musicians usually manifests as stiffness of one or more fingers and inability to open the finger once you’ve closed it. This is due to inflammation within the tendon sheath that prevents the tendon from moving smoothly (or at all). There may also be a popping sound when you flex your fingers.
Focal Dystonia is a mysterious condition that manifests much like tenosynovitis, but often without pain. One or more fingers may clench and not open. It is more often found in professional musicians who play for many hours a day over several years. Research has hinted that it’s a neurologic problem rather than an injury per se, but it isn’t yet fully known why the message from brain to finger gets scrambled. For the musician, this is especially strange considering that they’ve so carefully trained their brain-to-muscle impulses to be accurate and reliable, and in fact they were perfectly fine for many years of playing.
Thoracic Outlet Syndrome (TOS) is a condition that may arise due to overdevelopment of the muscles in the area behind the clavicle (collarbone) where major arteries and veins vie for space with muscles, tendons, the spinal column, the first rib, and the clavicle itself. Some people, maybe one in a hundred, actually have an extra rib (called a “cervical rib”) which makes this space even smaller. When a muscle becomes too large and hard from overuse, it can press a vein or artery against a bone or another muscle, causing impaired circulation. Nerves can be pinched as well. In the most extreme cases, the hands become swollen and blue or black. In less extreme cases, the hands and arms simply ache or tingle and swell slightly; this is often mistaken for arthritis. This syndrome is often caused by habitually holding the arms too high, so it’s common for harpists, violinists, floutists, and carpenters.
Here’s a test for Thoracic Outlet Syndrome: hold your arms out straight from your sides. Now bend them up at the elbows as though you were in a holdup (“Come out with your hands up!”). With the palms facing forward, slowly and smoothly open and close the fingers for three minutes. If within that time you cannot hold your arms up anymore, or if your hands hurt or cease to function, you may wish to see an occupational therapist, and you may need change the activity that overdeveloped the muscles.
To avoid the above conditions, learn a relaxed technique, don’t practice your music more than about two hours a day, and don’t play when your hands are cold. Warm them up under warm water first if necessary. Always avoid playing when your hands hurt.
More Sources of Pain:
Pain in the hand, wrist or arm may also be caused by chronically tight muscles in the neck, shoulders, or back, which can impinge on nerves that lead to the hand. This is called “referred pain”, but nerves that are affected this way also may not send the right messages to the hand (you might try to move a finger one way and it goes another, or it doesn’t respond right away).
Chronically tight muscles in the neck and back can also pull the vertebrae out of alignment, causing nerve entrapment (all nerves originate and emanate from the spinal column, spreading to the rest of the body like branches on a tree).
A good chiropractor, massage therapist, and/or accupressurist can help, and stress-reduction techniques such as yoga, meditation and biofeedback may eliminate the underlying causes. Don’t assume surgery is the answer for chronic pain unless all possible causes and other treatments have been addressed first. When surgery is suggested, be sure to get a second opinion, and maybe a third!
Referred pain and/or tingling in hands may also result from spondylosis in the neck – bone spurs on the vertebrae that compromise nerve function. This arthritic condition does sometimes require corrective surgery.
You may be advised by a physical therapist to wear a brace on your hand or wrist if you have pain doing normal everyday activities. If a brace makes your fingers swollen, tingly, or numb, get it properly refitted immediately.
A Checklist for Hands:
To reiterate, problems with hands/wrists/arms can be caused by:
- Tense hands
- Poor hand position/technique for YOUR hand size and shape
- Stretching thumb forward while playing (see previous post)
- Plucking or pressing too hard
- “Flying pinkie” (see previous post)
- Hand bent outward at wrist (inward is usually OK)
- Referred pain from poor ergonomics (see previous three posts)
Next week: more about hands!