THE HAND SURGEON’S APPROACH TO THE MUSICIAN
Much attention is given to sports injuries and many sport physicians, sport physiotherapists and even psychologists have focused exclusively on the athlete’s needs. The special needs of the musician are commonly overlooked and under-appreciated. Considering the technical skill required to perform at a high level, the long hours of practice and the biomechanical strain on muscles and joints, it is not surprising that the musician battles with a wide spectrum of musculoskeletal symptoms.
There are plenty of variables that should be considered when the musician is burdened by upper limb complaints: Postural and ergonomic positioning, the instrument, techniques applied (e.g. closed-finger versus wide finger technique), physiological considerations (like joint hypermobility), as well as psychological factors, all of which should be considered by the hand surgeon and therapist.
The most common symptoms that musicians present with are pain, cramping of muscles, weakness, tremors and less frequently sensory symptoms (pins and needles or numbness). The root of these problems are complex and even more so categorising them in syndromic bundles. Therefore, the team should carefully evaluate the physiological, psychological and ergonomic/instrumental factors.
It is important to understand that all the common hand conditions can present similarly in the musician. It is hard to know to what extent overuse or postural factors really play in the etiology of these conditions. The disability caused by these conditions probably has a greater effect on the musician. Common conditions like carpal tunnel syndrome (compression neuropathy of the median nerve) are frequently seen in musicians although there is no evidence that playing an instrument predisposes them to this condition.
Overuse syndromes refer to a non-specific syndrome especially in string players where pain, weakness, tingling, stiffness or loss of dexterity develop after prolonged playing. The extensor muscles with lumbricals (hand intrinsic muscle) of the ring and little finger are commonly affected in pianists, while the string player develops symptoms in the flexor groups of the right hand and wrist flexors of the left hand.
Thoracic outlet syndrome affects the musician when the nerves and vessels are compressed in the space between the neck and the axilla and is usually caused by poor posture. It is more common in females. The treatment for this condition is non-surgical.
Focal dystonia is very similar to “writer’s cramp” and frequently develops in piano players. It has affected many great names like Robert Schumann in the past and our understanding of this condition is still unclear.
Surgery remains the last resort for all of these conditions and is seldom indicated. The golden treatment, for most of these conditions, is rest and minor postural and ergonomic adjustments.