Musicians' Health Collective

Musicians' Health Collective: Supporting the health of musicians (and normal people)

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Help- I Have a Nerve Entrapment!

While musicians may not know exactly know how nerve compression works, we may know the physical sensations or have heard of them- numbness and tingling in the fingers, an inability to hold things or grip them, and sometimes tendonitis as well!  Nerve entrapment is when a nerve becomes compressed by surrounding tissues or irritated from sustained holding positions, misuse, overuse, etc.  For musicians, there are three nerves of the upper arm which are often affected: the radial nerve, the ulnar nerve, and medial nerve.  These nerves originate from the cervical spine and top of the thoracic spine  (aka. they start in the neck and upper back), move through the brachial plexus, and can be affected by movement patterns, lack of blood flow, tendonitis, etc. along the way to the hand.

The two most common areas of nerve entrapment affect the ulnar nerve via the elbow and median nerve via the wrist.  Carpal tunnel syndrome refers to the area in the wrist where nerves and flexor tendons pass through to the hand.  Tendonitis and inflammation in these flexors can press on the nerve, which might be caused by overuse, misalignment in technique, or repetitive trauma.  This could be because of how a student holds his or her instrument or bow, how he or she plays at the piano, or even types at the computer.  For string players, extreme wrist extension (elevated wrist when holding bow with fingers below) can also accelerate these issues. 

Cubital Tunnel Syndrome affects the ulnar nerve, and refers to the cubital tunnel in the elbow region where the nerve passes to the ulna.  The ulnar is the largest unprotected nerve in the body, meaning that it has very little soft tissue and muscle to protect it.  Each time you bend your elbows, your ulnar nerve is slightly compressed which is normal, but sustaining bent elbows for many hours a day can wreak havoc on this sensitive nerve.  Most musicians need to bend their elbows to 90 degrees to simply hold their instruments, and then add to that driving, computer use, eating, and sleeping, which can equal 20 hours of bent-elbow motion a day!  Also factor in that oboists and bassoonists will make reeds, most likely with bent elbows and sitting over a reed desk.  Compression in the ulnar nerve may lead to numbness and tingling in the pinky/ring side of the hand as well as the ulnar side of the forearm.

Lastly, radial nerve compression will affect the thumb side of the hand.  (Remember last week's radius vs. ulna mini anatomy lesson?)  This can occur in the elbow as well, though it will be in the inner pit of the elbow, unlike the ulnar nerve.  There can also be compression as the nerve travels into the hand, along the thumb side.  Excessive pronation, bow gripping, and over-gripping an instrument, can contribute to these issues.

Now this may look rather bleak, especially when nerve compression is coupled with surrounding tissue inflammation or tendonitis, but we'll take a look at some prevention strategies next time, as well as common treatments.

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Tissue Issues: Help! My student has tennis elbow!

Tennis Elbow-a mysterious and slightly perplexing name for a form of tendonitis, or an inflammation of the tissues that connect muscle to bone.  Tennis elbow is also called lateral epicondylitis, because the bulk of the tendons attach at the lateral epicondyle of the humerus. (which you can see in the previous post's images of bones)  The lateral epicondyle is a fancy way of saying the bony protuberance of your upper arm which makes up your elbow. (although there is also a lateral epicondyle of your femur, fyi.)

Image from, created by  Paul Roache MD.

Image from, created by Paul Roache MD.

      While that information is all well and good, let's go deeper.  The muscles and subsequent tendons that attach at the lateral epicondyle are your extensors (they extend the fingers and wrist) and the muscles of supination.  If the muscles of the forearm are extremely tight, they can put more strain on the tendon, as well as non-ergonomic positions, overuse,  and lack of blood flow.  (This is of course in conjunction with fascial issues which may extend far beyond the site of sensation, which is a concept I will explain in the upcoming weeks.)  This is perhaps a less common form of tendonitis in musicians, although I have heard of it mostly with guitarists and flutists because of extreme wrist angles while handling the instrument.  Movements that will hurt include, (surprise!), extending the wrist and fingers and supinating.  Unfortunately, those are crucial muscles to many instrumentalists.  So what does one do?

1.  Rest the area of pain and inflammation, and see a doctor for more medically specific guidance.

2.  Possibly take anti-inflammatory medicine, if you are into that.

3.  Ice the area, and eventually alternative ice and heat.

4.  Start re-evaluating your setup or your student's setup and the "global" plan.  What do I mean by that?  While there may be sensation at a localized site, tension patterns usually resound throughout a fascial and muscular area, meaning that there may be issues in the tissues of the shoulder, back, biceps, hips, hamstrings, calves, etc.  Ask yourself and your student these questions:

Where are other sites of tension, past injury, asymmetry, and discomfort?  Are there body-reading discrepancies that you can see?  Does he or she grip the bow too firmly?Does he or she enthusiastically pick up the fingers off the fingerboard or keys with excessive force?What other activities does he or she engage in?  How does he or she hold a pencil, write, and use the computer/cell phone?  Sometimes tendonitis is not the result of one action or one activity, but the composite of inefficient movement patterns manifesting in different areas of life.

5.  If you can't assist your student, or you're at a loss of what to do with your own setup, find a teacher who has experience and knowledge of injuries and tension patterns.  (stat!)  Some tendonitis issues are extremely complex, and it's great to have a different perspective on setup issues, especially when resolving a long standing habit and preventing nerve entrapment.  In addition think about other mind-body support methods, such as Alexander Technique, Feldenkrais, and Rolfing, to name a few.

6.  Lastly, once these other avenues have been explored, start reassessing your practice time habits (or your students') and talk about practice breaks, warmups, and stretches (once inflammation has decreased.)

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