IN BRIEF

Injuries Complicating Musical Practice and

Performance: The Hand Surgeon’s Approach to the
Musician-Patient
Andrew J. Rosenbaum, MD, Jacqueline Vanderzanden, MD,
Andrew S. Morse, MD, Richard L. Uhl, MD

IGH-PERFORMANCEmusculoskeletal inju- skeletal sequelae can arise from continuous repetition

H ries in the instrumental musician stem

from repetitive motions, awkward pos-
tures, and long practice hours. Although their pre-
while trying to learn a difficult passage, or when a
musician accustomed to the closed-finger technique of
Mozart must suddenly adapt to the wide finger stretches
cise prevalence in this population is unclear, many of Brahms or Liszt.1
have attempted to quantify this number and delin- In a study by Knishkowy and Lederman, the pre-
eate the specific problems.1,2 senting symptoms of 52 musicians with musculoskele-
Although the musculoskeletal conditions affecting tal or neurological problems of the upper extremities
musicians have been acknowledged since the early
were evaluated. These symptoms were stratified based
1700s, the prevailing mantra has been that of “no pain,
on the specific instrument played: string, keyboard, or
no gain.”3,4 Performing arts medicine developed as
wind. Pain was the predominant complaint in all
health care providers began to understand the anatomic
groups. The other symptoms identified were loss of
and physiologic stresses endured while playing an in-
dexterity, cramping/stiffness, weakness, tremors, swell-
strument and their associated injury patterns. It is a
collaborative field of both nonsurgical and surgical spe- ing, and clicking.2
cialists devoted to understanding and treating injures The physical examination of the musician should
that frequently complicate musical practice and perfor- consider both intrinsic and extrinsic factors. Patients
mance.3,4 should be evaluated with and without their instruments,
because some symptoms might appear only while play-
CLINICAL APPROACH TO THE ing. Simple variables such as the size, weight, and string
MUSICIAN-PATIENT tension can create a mismatch between the musician
When musicians present to a hand surgeon, they have and instrument, accelerating the development of upper

likely exhausted their own attempts at self-diagnosis
and treatment, in addition to having seen other health
care professionals previously.5 Despite this, the initial
evaluation requires a compete history and physical ex-
amination.
The instrument played, level of technical attainment,
practice habits, and technique applied must be investi-
gated. Often, a sudden increase in practice time or
intensity can stress muscle tone. Significant musculo-
From the Division of Orthopaedic Surgery, Albany Medical Center, Albany, NY.
Received for publication August 16, 2011; accepted in revised form January 16, 2012.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Andrew J. Rosenbaum, MD, Albany Medical Center, 43 New Scotland
Avenue, Albany, NY 12208; e-mail: andrewjrosenbaum@gmail.com.
0363-5023/12/37A06-0033$36.00/0
doi:10.1016/j.jhsa.2012.01.018
In Brief
extremity injuries.3 It might become evident while ob-
serving a performance that a simple adjustment such as
repositioning a chin rest or adding a shoulder rest could
alleviate many of the musician’s symptoms.2 In the
absence of examination with instrument in hand, such
simple and effective treatments can be overlooked.
Extrinsic factors can affect the distribution of work-
load to a given muscle group. Sensation, motor func-
tion, and perfusion should always be assessed. In addi-
tion, range of motion and joint laxity should be noted,
because these traits can be either beneficial or hurtful to
the musician. Joint hypermobility can be problematic in
that muscle contraction becomes the primary stabiliza-
tion of the affected, ligamentously lax joint. In this
setting, the prolonged need for dynamic stabilization
leads to pain, fatigue, and spasm.6 Furthermore, hyper-
mobility can lead to digital nerve compression, traction

©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1269

 1270 INJURIES AND MUSICAL PRACTICE

neuropathies, and the development of a traumatic sy- treated with analgesics and anti-inflammatory
novitis in the affected joints.6 agents during this phase. The rehabilitative phase
commences when the musician–patient is pain
OVERUSE SYNDROME free; it involves exercises to stretch and strengthen
Overuse syndrome is the most common affliction of the muscle–tendon unit.3 Players can then gradu-
instrumental musicians. This disorder represents the ally begin playing but must rest if fatigue or pain
culmination of playing beyond the point of muscle returns.1 By following this regimen, 80% of pa-
fatigue and can present with tients are eventually able
pain, weakness, tingling, fa- EDUCATIONAL OBJECTIVES to return to normal playing
tigue, stiffness and decreased ● Discuss the important factors to obtain during the initial history of a mu- schedules.2
dexterity.1,7 During both sician with upper extremity pain. Treatment can be supple-
practice and performance, ● State the difference between the technique of Mozart versus Brahms or mented with extremity or-
thousands of notes are Liszt. thotics or instrument modifi-
played, mandating precision ● List the variables that can create a mismatch between the musician and cation, such as using custom
of force and timing of joint instrument. chin and clavicle rests for the
flexion, extension, and rota- ● Discuss the role of joint hypermobility leading to pain, fatigue, spasm, and violin or viola or playing
tion.2 The most critical risk synovitis. with a curved flute. This mo-
factor is constant repetition ● State the risk factors for overuse syndrome in the musician. dality can unload com-
during hours of intense prac- ● Summarize treatment of overuse syndrome in the musician. pressed areas, reducing the
tice.3 Female gender and a fatigue and pain seen with
sudden increase in playing Earn up to 2 hours of CME credit per JHS issue when you read the related overuse syndrome.1
time are additional risk fac- articles and take the online test. To pay the $20 fee and take this month’s
tors.8 String players are most test, visit http://www.jhandsurg.org/CME/home. THORACIC OUTLET
commonly affected, whereas SYNDROME
9
percussionists are the least affected. Thoracic outlet syndrome (TOS), a term coined by Peet
Musculotendinous overuse syndrome is typi- et al in 1956, encompasses a number of clinical syn-
cally found in the hands, wrists, and forearms, with dromes attributed to neural or vascular compression
the muscle–tendon unit involved being largely de- between the neck and axilla, a space crowded with
termined by the specific instrument.3 In pianists, it blood vessels, muscles, and nerves.12 Thoracic outlet
is the extensors of the wrists and fingers, along syndrome is relatively common in musicians, especially
with the lumbricals of the ring and small fingers, flutists, likely because of the postures they adopt while
In Brief

that are commonly affected. String players have
problems with the flexors and extensors of the
right hand, in addition to the muscles involved
with ulnar deviation in the left hand.
There are three predominant theories pertaining
to the mechanism of musculotendinous overuse.
The first, presented by Fry, involves injury to
muscles, tendons, ligaments, and joint capsules,
and tendon sheath inflammation.10 Eccentric con-
traction was described by Lederman, involving
injury to the musculotendinous junction secondary
to overstretching of contracting muscles.11 Inflam-
mation of the tenosynovium is the third theory,
which was described by Hochberg. 7 tients.13 His cohort consisted of 5 pianists, 9 string
The treatment of overuse syndrome is divided
into two phases: acute and rehabilitative. During
the acute phase, complete rest or a period of lim-
ited playing of the instrument is required. The
amount of rest depends on the duration, severity,
and localization of the problem. A minimum of 12
1,5
weeks is typically advocated. Symptoms can be
playing their instruments.1,5 Women are more likely
than men to develop TOS. Poor posture and obesity are
further exacerbating factors.
Because there is no one treatment that works for all
patients with TOS, a multidisciplinary approach is often
required. Nonsurgical treatment, including nonsteroidal
anti-inflammatory agents, weight loss, stretching, pos-
tural changes, and strengthening exercises should be
tried first. If these modalities fail, surgical intervention
might be necessary.5
In a paper specifically devoted to TOS in musicians,
Lederman discussed his own observations on 17 pa-
players, and 3 wind instrumentalists. Of the 15 treated
conservatively with postural therapy, strengthening, and
range of motion exercises, 11 improved significantly or
3 completely, 2 were unchanged, and 1 patient experi-
enced minimal improvement. The 2 patients who had a
first rib resection completely recovered and were able to
resume full playing. It is evident from this that there are

JHS 䉬 Vol A, June 

 INJURIES AND MUSICAL PRACTICE
several routes one can take in treating TOS in musi-
cians, with good outcomes possible.
NERVE ENTRAPMENT SYNDROMES
When a musician presents with complaints of pain, loss
of strength, and sensory abnormalities, distal nerve en-
trapment syndromes must be considered in the differ-
ential diagnosis. Although there is no evidence to sug-
gest that musicians are more susceptible to nerve
entrapment syndromes, the resulting loss of dexterity
and finger control makes activities such as playing the
piano, strumming the guitar, or manipulating the bow of
a cello next to impossible. Many musicians might ex-
perience symptoms only while playing.3
The initial work-up and diagnosis of entrapment
neuropathies in instrumentalists is similar to that of
nonmusicians, with an emphasis on physical examina-
tion and specific provocative maneuvers. Electrodiag-
nostic studies can be obtained to help confirm the di-
agnosis. It is important to note, however, that the
electrodiagnostic studies are often normal in musicians
because their symptoms are commonly intermittent and
present only while playing.3
Treatment should be similar to that for non-
musicians, conservative modalities followed by opera-
tive intervention. Postural changes, splinting, nonsteroi-
dal anti-inflammatory agents, and injections of steroid
into the carpal tunnel might be effective. If not, carpal
tunnel release may be necessary. With ulnar neuropa-
thy, simple decompression or transposition might be
required. Successful outcomes in musicians have been
described with all types of treatment.2
Warm-up and cool-down stretching exercises and
frequent practice breaks are also essential.14
FOCAL DYSTONIA
Analogous to “writer’s cramp,” focal dystonia was de-
scribed as the “pianist’s cramp” in 1887 following a
lecture by the British physician Dr. Vivian Poore.15 It is
a painless motor control disorder involving sustained
muscular contraction, leading to twisting and abnormal
posturing that occurs during one complex motor act,
such as playing the piano, but not others requiring a
similar level of precision.16 In instrumental musicians,
it can involve one or both of the upper extremities and
more commonly affects distal muscle groups.5
Focal dystonia has affected pianists Leon Fleisher,
Gary Graffman, and Robert Schumann, as well as vio-
linist and violist Pinchas Zukerman. Its incidence is
uncertain but has been estimated to be between 1 in 200
to 500 versus 1 in 3,400 in the general population.17,18
Wind players appear to be particularly susceptible.5
JHS 䉬 Vol A, June 
1271
The pathophysiology and risk factors of focal dysto-
nia are unclear. Both genetic predisposition and specific
triggering events, such as a trauma, have been pro-
posed. In one theory, a basal ganglia–mediated process
is implicated, in which excessive motor cortical excit-
ability, combined with abnormal cortical sensory pro-
cessing, occurs.14 Regardless, a correlation exists be-
tween the muscle groups involved in the repetitive
motor activity essential for playing an instrument and
those that are dystonic.
Focal dystonia is a clinical diagnosis. Symptoms,
which begin insidiously, almost exclusively occur while
playing the instrument and include involuntary move-
ments and postures, stiffness, and cramping. The patient
must, therefore, be examined while performing. Other
diagnostic modalities, such as electrodiagnostic studies,
have limited utility, primarily because of the inherent
difficulty in coordinating the performance of such stud-
ies during a symptomatic period.14
Current management options are limited and focus
on technical retraining, a practice that attempts to purge
a musician of a presumed maladaptive motor sequence
in hopes of developing a more normal pattern. This is
sometimes supplemented with anticholinergics and/or
botulinum toxin injection, which have been shown to
have only modest benefits in musicians.5,14 Although
stereotactic neurosurgical procedures such as thalamo-
tomy have been performed for focal dystonia refractory
to conservative treatment, it was thought that the risks
of brain surgery typically outweighed the disability
incurred with focal dystonia.19 However, deep brain
stimulation has received recent attention as a safer and
In Brief
effective neurosurgical treatment option for focal dysto-
nia.20 Although this is promising, further research re-
garding the specific areas of the brain that it must target
as well as studies analyzing its long-term outcomes
must be conducted.20
OTHER CONSIDERATIONS
Although treatment of these conditions in musicians are
initially conservative, surgery should not always be
thought of as a last resort, especially if earlier surgical
intervention will result in better restoration of function
and/or a shorter recovery period.
It is often helpful to plan surgical incision locations
while the musician is holding his or her instrument to
avoid tactile areas and to ensure that the incision is
placed in tension-free zones.
There are some fractures, such as those of the meta-
carpals and phalanges, in which mild angulation and
rotational malalignment might be acceptable, and even
imperceptible, to the average person, but severely de-
 1272 INJURIES AND MUSICAL PRACTICE
bilitating and detrimental to the musician.21 Thus, be-
cause even the slightest decline in function can prema-
turely end a musician’s career, anatomic restoration
must be the standard.
Similar to care of elite athletes, musculoskeletal care
of a musician requires a thorough understanding of the
extraordinary demands that these patients place on their
upper extremities to be able to return them to their
pre-injury level of function.
REFERENCES
1. Rozmaryn LM. Upper extremity disorders in performing artists. Md
Med J 1993;42:255–260.
2. Knishkowy B, Lederman RJ. Instrumental musicians with upper
extremity disorders: a follow-up study. Med Probl Perform Art
1986;1:85– 89.
3. Lockwood AH. Medical problems of musicians. N Engl J Med
1989;320:221–227.
4. Brandfonbrener AG. Musculoskeletal disorders of instrumental mu-
sicians. Hand Clin 2003;19:231–239.
5. Lederman RJ. Neuromuscular problems in musicians. Neurologist
2002;8:163–174.
6. Hansen PA, Reed K. Common musculoskeletal problems in the
performing artist. Phys Med Rehabil Clin N Am 2006;17:789 – 801.
7. Hochberg FH, Leffert RD, Heller MD, Merriman L. Hand difficul-
ties among musicians. JAMA 1983;249:1869 –1872.
8. Amadio PC. Management of nerve compression syndrome in musi-
cians. Hand Clin 2003;19:279 –286.
JOURNAL CME QUESTIONS
Injuries Complicating Musical Practice and
In Brief
Performance: The Hand Surgeon’s Approach
to the Musician-Patient
What is the most predominant complaint in
musicians complaining of upper extremity
ailment?
a. Impaired dexterity
b. Pain
c. Cramping
d. Weakness
e. Clicking
To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.
JHS 䉬 Vol A, June 
9. Hoppmann RA, Patrone NA. A review of musculoskeletal problems
in instrumental musicians. Semin Arthritis Rheum 1989;19:117–126.
10. Fry HJH. Overuse syndrome in musicians, prevention and manage-
ment. Lancet 1986;2:728.
11. Lederman RJ, Calabrese CH. Overuse syndromes in instrumental-
ists. Med Probl Perform Art 1986;1:7–11.
12. Peet RM, Henriksen MD, Anderson TP. Thoracic outlet syndrome:
evaluation of a therapeutic exercise program. Mayo Clin Proc 1956;
31:281–287.
13. Lederman RJ. Thoracic outlet syndromes: review of the controver-
sies and a report of 17 instrumental musicians. Med Probl Perform
Art 1987;2:87–91.
14. Lederman RJ. Neuromuscular and musculoskeletal problems in in-
strumental musicians. Muscle Nerve 2003;27:549 –561.
15. Poore GV. Clinical lecture on certain conditions of the hand and arm
which interfere with the performance of professional acts, especially
piano-playing. Br Med J 1887;1:441– 444.
16. Pesenti A, Priori A, Scarlato G, Barbieri S. Transient improvement
induced by motor fatigue in focal occupational dystonia: the hand-
grip test. Mov Disord 2001;16:1143–1147.
17. Tubiana R. Musician’s focal dystonia. Hand Clin 2003;19:303–308.
18. Schuele S, Lederman RJ. Long-term outcome of focal dystonia in
string instrumentalists. Mov Disord 2004;19:43– 48.
19. Volkmann J, Benecke R. Deep brain stimulation for dystonia: patient
selection and evaluation. Mov Disord 2002;17:S112–S115.
20. Cho CB, Park HK, Lee KJ, Rha HK. Thalamic deep brain stim-
ulation for writer’s cramp. J Korean Neurosurg Soc 2009;46:
52–55.
21. Winspur I. Special operative considerations in musicians. Hand Clin
2003;19:247–258.
What variables can create a mismatch between
the musician and instrument, accelerating the
development of upper extremity injuries?
a. Size
b. Weight
c. String tension
d. All of the above