Lateral epicondylitis ('tennis elbow')
‘Tennis elbow’ is a condition in which the outer edge of the elbow, just below the elbow joint, becomes tender or painful. (Pain on the inside of the elbow is known as ‘golfers’ elbow, which will be discussed on this website at a future date. The exercises below are also relevant to ‘golfer’s elbow’, as they all aim to release unnecessary tension in the elbow and forearm). The pain may also spread down the forearm and into the hand. Because of the frequent occurrence in tennis players, it is commonly known as tennis elbow, although people in other professions, including keyboard players and computer users are also affected.
Causes and triggers
Tennis elbow in pianists may either develop gradually from prolonged practice or be triggered by a sudden increase in playing time and intensity. The main contributing factors are thought to be a combination of:
• Tension (‘grip’) in the elbow whilst playing, especially when playing forte.
• Regular gripping (or curling) action of the fingers.
• Over-extension of the wrist (playing with a low wrist).
• Rotating from a tense elbow.
• Repeated impact against the keys (playing repeated chords or octave with a tense arm).
Added to this, a pianist may already have poor posture, tight shoulders and arms and faulty alignment of the forearm, all of which contribute to arm tension and may increase the potential for pain.
If any pain is experienced in the elbow, an accurate diagnosis from a medical specialist (ideally someone experienced in musicians’ problems) is crucial. Recommended treatments may include:
Rest initially to allow the tissue to heal
A brace, support bandage or splint will minimise movement and encourage rest
Ice to reduce inflammation
Elevation : lifting the elbow above heart-level will help to reduce swelling.
Physiotherapy, or osteopathic exercises to rebalance the muscles or massage
Topical NSAID creams or gel
Surgery would only normally be considered if the pain is severe and long-lasting, and other options have been fully explored.
My experience is that once pianists release the tension in the elbow, the whole arm starts to coordinate with ease, the sound improves and the pain starts to dissipate.
It may also be beneficial to reassess your overall sitting posture (See Sitting Posture in the Online Academy and the Yoga for Musicians DVD), checking that you have a well-balanced torso, with the elbow hanging passively. Some help from an Alexander technique teacher might be helpful.
When a hand or arm has been injured, the muscles tend to lose some of their elasticity. My ‘passive stretching exercises’ can be especially beneficial as they help to regain elasticity and full range of movement whilst keeping the elbow completely relaxed. The exercises show how to dissociate movement in the hands and fingers from tension in the elbow, which will become particularly important when you start to resume playing.
'Namaste sequence’: Place your hands in ‘prayer position’ in front of your chest. Then invert the hands so that the fingers point downwards and the backs of the hands touch each other. Alternate between the two in a flowing motion, keeping the wrist and elbow soft.
‘Floppy arm': Place your hand in playing position on a flat surface. Lower the wrist and elbow very gently, then raise them. Repeat the movement, keeping the arm very floppy and check for any tension in the wrist or forearm. Do each stretch in time with your breathing – always breathing out as you lower the arm.
‘Elastic elbow’: Place your hands lightly on the closed fallboard of the piano. ‘Dust the wood’ by sliding your hands very lightly along the wood towards the extremes of the keyboard, then forward and back and in circular motion. Open up the elbow joint to allow the arm to straighten and move freely.
‘Freely moving hand and fingers’: Rest your arm on the arm of an armchair. Let the elbow and forearm relax fully. Move the hand in all directions, up/down, side-to-side and in circles, as far as possible without tensing the elbow. Then move each finger and thumb in all directions without tension.
‘Opening the hand like a fan’: Rest your arm on the arm of an armchair. Open out the hand extremely gently from the base of the palm (as if reaching towards an octave) whilst keeping the whole arm relaxed.
Do each movement in time with your breath – always breathing out into the stretch.
Roskell piano exercises for tennis elbow
When the pain has subsided and you start to resume some playing, it is very important to build up practice time very gradually and to stop as soon as you experience pain. (See Recovering from injury). Use this time to explore a new approach to technique.
There is no point in going straight back into old habits which may have contributed to the problem in the first place!
The Complete Pianist
There are numerous sections in The Complete Pianist which can be of particular benefit to pianists with tennis elbow, including:
The pianist's elbow
Releasing elbow tension: Dusting the keys
The neutral wrist
Bringing the hands to the keyboard
Avoiding co-contraction (gripping with a low wrist)
The Parachute touch with a ‘springy elbow’
Effortless rotation exercises
The above exercises all help to rebalance the muscles, release tension in the elbow and other joints, and cushion the impact of the hand on the keys. Study the exercises initially with the non-affected arm, then gradually develop a daily routine for the affected arm, adding a new exercise as and when you feel that the hand can tolerate more activity.
Before regaining a full playing schedule it is also important to explore how to play forte without clenching the elbow. The chapters on The Parachute touch in chord playing and Full arm release in The Complete Pianist show how to engage the upper arm in the sound production whilst keeping the elbow soft.
Other potential triggers
Observe how you use your elbows in your everyday life. Do you hold your elbows tense when typing, texting, playing sport or carrying shopping? Look for other ways to do these activities without clenching the elbow. A physiotherapist, occupational therapist or experienced teacher may be able to help you learn how to avoid tensing the elbow in your other activities.
A more extended version of this page, including videos, will shortly be available on the Online Academy