By Emily Wright | From the January-February 2024 issue of Strings Magazine
Great string players make their work sound effortless as musical intention takes wing. But it isn’t effortless. It requires a great deal of carefully synchronized physical exertion, special technical skills honed during long hours of practice. And, as is the case with any form of physical exertion, it sometimes leads to injury.
Finding the help you need for an injury sustained by playing a stringed instrument isn’t always so simple as calling your own doctor. There are fewer physicians who specialize in the kinds of physical problems that plague musicians than there are those who focus on sports injuries. So it’s important to know what to do when you’re hurt and to whom you should place a call for an appointment. Believe me, I know. A lifetime of injuries and misdiagnoses has been quite an education in navigating the world of performing arts medicine. Here’s what I wish I had known when that first shock of pain ran through my wrist as a young cellist.
Tendons are thick cords of tissue that connect muscle to bone. Persistent overuse or sudden increases in a particular activity are the primary causes of tendon inflammation, referred to as tendinitis. String players preparing for an audition, performance, or competition frequently develop tendinitis in elbows, wrists, and shoulders. Playing with tension and rigidity taxes tendons, too—it’s possible to develop the searing pain of tendinitis without the long hours and overuse typically associated with the condition.
When a tendon is put in a position where it creates friction with the protective sheath that surrounds it, the sheath itself can become swollen and inflamed. While it can happen anywhere in the body, string players primarily see it in their wrists—a condition called De Quervain’s tenosynovitis. Not sure what’s ailing your wrist? There’s a quick at-home diagnostic called the Finkelstein maneuver you can try: Tuck your thumb into your palm and close your fingers around it in a gentle fist. Bend the wrist down toward your little finger. If the pain sharply increases, that’s usually a decent indication that the tendon sheath is inflamed.
The first line of defense with tendon inflammation is the RICE protocol—rest, ice, compression, elevation—although recent research suggests that it is not as broadly helpful as once believed. The rest and ice certainly make sense in terms of physically reducing the scope of inflammation, but differences in physiology and the genesis of the problem need to be taken into consideration. Non-steroidal anti-inflammatories are often used in combination with rest, but they do not address the source of the problem and can mask ongoing issues. The same can be said of steroid injections, which can work wonders but have significant tradeoffs. Repeated injections can weaken tendons and destroy cartilage, so they are best thought of as emergency measures. After the tissue has healed, physical therapy and modifications in technique are your best bets to avoid another flareup.
Nerves deliver motor control and sensation to our bodies, and when they are compressed or damaged, the initial symptoms can resemble common overuse injuries, especially tendinopathy. It doesn’t help that some nerves travel through areas like the brachial plexus (your shoulder), so crammed with essential structures on top of and betwixt each other that it’s a miracle any of us can use our arms at all. Sometimes the nerves passing through this juncture can get crushed, causing pain, tingling, weakness, and numbness in the arm and fingers of the affected side, resulting in what’s called thoracic outlet syndrome, or TOS.
Occasionally this happens in people who are born with a so-called cervical rib, which crowds an already busy spot with a structure that affords no flexibility to the highway of veins and nerves that pass close to it. Aside from novel physiology, TOS is often caused by car accidents or falls where the neck whips around, even if no hospitalization is required. Other times, it can present after a period of holding the body in maladaptive positions—shortening the neck muscles and pulling the collarbone against the structures around it.
There is a veinous version of TOS, where the veins passing through the brachial plexus are affected instead of the nerves. Though less common, it’s worth knowing about. Weak pulse, throbbing, swelling, and changes in skin color or temperature in the arm and hand are the classic symptoms. Definitive diagnosis of TOS is usually found via an ultrasound performed by a specialist, frequently a vascular surgeon. Sometimes physical therapy or an injection of a paralytic toxin like Botox into the offending neck muscles is adequate to relieve symptoms. For more profound cases, there are surgical options. For example, I had my cervical rib removed (ouch), my neck’s scalene muscles taken out (gross), and the pectoralis tendon in my chest snipped (yikes), but I regained nearly all of the sensation in my left hand right away. TOS is something of a controversial topic, with some physicians dubious as to its validity as a diagnosis at all. Since it mimics other more common conditions, it is frequently a long haul between first symptoms and accurate diagnosis.
Carpal tunnel syndrome (CTS) happens when the median nerve that provides movement in the forearm, wrist, and hand becomes irritated or squeezed as it passes through the wrist. This can happen as a result of overuse, scar tissue after an injury, fluid retention, or swelling due to conditions like rheumatoid arthritis. Women are more likely to experience CTS, and the onset of menopause is correlated with higher risk of developing it. The symptoms present as a strong ache in the hand and wrist, tingling, and loss of sensation or coordination. Building breaks into long periods of playing, keeping hands warm with a heating pad, finishing up with a cold pack to decrease swelling, and being scrupulous with technique are the best defenses against carpal tunnel issues. For moderate symptoms caused by overuse, you can try taking time off and using a splint to keep the wrist straight (especially at night). And a course of ibuprofen usually resolves the problem. For persistent debilitating symptoms, usually a provider will encourage a steroid injection before proceeding to surgery to free the compressed nerve. The ulnar nerve that passes through the elbow has similar presentation of symptoms, causes, and course of treatment.
Cervical Spine Dysfunction
The cervical spine runs from the base of the skull (joint C1) to the bony prominence at the top of the back (C7) and is densely packed with structures running in and around it: arteries, nerves and their roots, ligaments, and overlapping sheets of musculature. This crucial axis of sensation and coordination is vulnerable to a particularly insidious kind of injury, one subtly incurred over years of only mildly maladaptive posture.
String players—particularly cellists and bassists—are prone to a slight but meaningful “chin forward” posture and a concave torso, with the shoulders rounding forward. This puts stress on the muscles of the upper back and neck, which, when held out of position for long enough, get recruited to perform jobs they were never designed to do.
In proper alignment, the head exerts something like ten to 12 pounds of force on the spine. By jutting the chin forward by even two inches, that force triples. A head that is three inches out of alignment exerts over 40 pounds of force on the spine! The first symptoms may be burning between the shoulder blades or a headache. Over time, the spine (which is degenerating of its own accord due to age and normal wear and tear) begins to change to accommodate the burden. Depending on your physiology, treatment can be as simple as posture correction and strengthening, or as complex as disc replacement and a lifetime of maintenance. Sometimes postural problems cause compression at the nerve root, resulting in radiculopathy: pain, numbness, or weakness that radiates along the path of the nerve.
Central Sensitization Syndrome
Sometimes the body heals, but for reasons not entirely clear to modern medicine, the brain keeps sending pain signals. Pain serves in part as a warning to the body, telling us to stop doing a particular action to protect an injured or inflamed region. One of the working theories is that the body doesn’t recognize the healing, so it continues to take responsibility for preventing re-injury by sending acute pain signals, frequently out of proportion to the stimulus. Many pain specialists see an emotional component as well; that for people whose injuries have curtailed their ability to do an activity, the anxiety and fear of permanent loss creates a feedback loop in the brain. It is seen more in people with a history of trauma, chronic stress, and depression and should not be dismissed as “all in your head.”
Along with a persistence in pain symptoms, patients also can exhibit hypersensitivity to touch, sound, bright light, smells, medications, and food. These symptoms are manifestations of physical, functional, and chemical changes in the brain. The good news is that if the brain is plastic enough to create this new problem, with work, it can be bent back into a less painful shape. Treatment consists of cognitive behavioral therapy and gradual exposure to stimuli to recondition the associations and expectation of pain.
Finding the Right Physician
For new symptoms, the first person to see is your general practitioner: it’s important to have someone involved who sees you with some regularity and can incorporate whatever is going on into the larger picture of your overall health, as well as providing advice and referrals to specialists. Aside from the phenomenal neurosurgeon who saved my career (and maybe my life), my favorite doctors are physiatrists. These folks specialize in thinking of the body as a collection of interconnected systems and structures, which comes in handy if, for instance, your elbow is sore, but the problem resides in your neck.
Seeing a physiatrist in concert with an osteopath, neurologist, or other specialist can prevent the scope of the search for answers from narrowing prematurely. Any therapeutic intervention must be combined with changes in habits and an understanding of what caused it all in the first place.
To start, there are some general rules to remember when you’re developing healthy playing habits.
Breathe. Sure, your brain needs oxygen to function, but holding that inhale while panic-flailing through your repertoire also causes a cycle of physical tension and mental distress. It’s better for the music, your body, and your brain to learn to breathe gently while you play. A great place to start is to begin whatever you’re playing on a long exhale. We always inhale; it’s the exhale that gets forgotten.
Nerves and tendons like to run in straight lines and gentle curves. The wrist is particularly sensitive to excessive bends in either direction. Keep this in mind with your playing technique, but also the way you drive and the position you sleep in.
Muscles appreciate warm ups and cool downs. If you don’t already, add a five-minute preamble to your usual practice routine with the idea being to gently reintroduce the body to the physical demands of your instrument.
Bones and cartilage wear out over time; support them with posture, movement, and muscle. It’s never too late to hit the gym or do some weight-bearing exercises at home. Think of your body as a fortress that will protect you so long as you fortify it as the years pass. I made the mistake of avoiding exercises that challenged my arms and back, thinking I was protecting myself. Alas, this instinct likely contributed to the series of escalating surgical interventions that would see my performance and recording career wildly curtailed. Not sure where to start? After clearing it with your doctor, create your own routine!
Here’s the regimen I follow:
- Foam roller pectoralis stretch and diaphragmatic breathing
- Yoga hip opening series: pigeon, cow face, cobblers poses
- Foam rolling hips and glutes to release tension
- Shoulder shrugs with weights
- Seated lateral row
- Resistance training with elastic bands
- Varying cardio stuff: treadmill, ice skating, hiking, swimming
Using the body as a whole and moving blood around it is unambiguously good for you. Do what you can when you can. I am a chronic pain person, and some days this stuff isn’t an option. If you’re having a tough symptom day, granting yourself some grace is the healthiest thing you can do for body and mind.
Last (and stop me if you’ve heard this before): sleep is the foundation of health. Take changes in quality or amount of sleep seriously. Try to learn to sleep on your back at least some of the time. The right pillow can be miraculous for both posture and quality of rest.
Wishing each of you health, comfort, and many years of music to come.
The content of this article is for informational purposes only and is not to be considered medical advice or in any way comprehensive. Only licensed medical professionals can properly diagnose and treat any of the conditions described.
Specialist Centers for Musicians with Injuries
- Cornell Center For the Performing Artist (Ithaca, New York)
- Eastman Performing Arts Medicine (Rochester, New York)
- Cleveland Clinic Center for Performing Arts (Cleveland, Ohio)
- Courage Kenny Rehabilitation Institute (Minneapolis, Minnesota)
- University of Michigan Performing Arts Rehabilitation Center (Ann Arbor, Michigan)
- Mount Sinai Louis Armstrong Center for Music and Medicine (New York, New York)
- Brigham and Women’s Hospital Performing Arts Clinic (Boston, Massachusetts)
- University of Southern California Performing Arts Medicine Center (Los Angeles, California)