Forearm and hand pain
Tendonitis and RSI in Pianists
Forearm and hand pain can be linked to a number of conditions so it is important to get an accurate diagnosis from a medical specialist (see the BAPAM website for a recommended list of practitioners in the UK or to make an appointment at one of their clinics).
It can be rather confusing, as different doctors use different terms. The most commonly used terms nowadays for the kind of non-specific forearm pain that pianists often experience are ‘work-related upper limb disorder’ or ‘non-specific upper limb pain’. As this type of pain is often associated with repetitive movement it was previously known as R.S.I. (repetitive strain injury). It is also linked with forceful movements, hence its other name ‘Overuse – or misuse – syndrome’. As the pain is often caused by inflamed tendons, the term tendonitis (also called tendinitis or tendinopathy) may be used.
Symptoms of tendinitis
There are many possible reasons for forearm and hand pain, so it is important to get an accurate diagnosis from a medical specialist. One possible cause of your pain is inflammation of the tendons. Tendonitis can be very debilitating for a pianist. Symptoms vary, but may include:
Pain or tenderness
Tingling or numbness
Pain may be localised, or may spread throughout the arm. It may come suddenly in response to movement or it may be continuous. There are many forms of tendonitis, just as there are many tendons in the shoulder, arm and hand.
What are tendons?
Tendons are fibrous tissue which attach bones to muscles. The bones of the fingers and thumb are attached by tendons to strong muscles situated in the forearm. Tendons are not very elastic or stretchy – it is the muscles which lengthen and shorten to move the bones. Tendon problems often arise when the tendons rub repeatedly against bones or ligaments. As piano playing involves repetition at speed, often at force and over long periods of time, tendons may become stressed beyond their natural limit. Any technical imbalance, such as a very high or low wrist, is likely to increase friction on the tendon as it passes over the joint. Over time the tendon may become inflamed and tender or painful. As tendons have rather a poor blood supply, they may take quite a long time to heal.
Forearm pain and tendon-related problems can be caused by a variety of tasks. They are particularly associated with doing forceful or repetitive activities at speed over a long period of time. Poor posture can also cause muscular imbalance, which can cause some muscles and tendons to overwork while others are weak. Forearm tension (co-contraction) and overly forceful movements may over time lead to pain. As piano playing involves repetitive activity, often at speed and with force, professional pianists in particular are at risk of experiencing some arm or hand pain at some point in their career.
It is important to reflect on what may have caused the pain, so as to be better able to prevent future recurrences. Here is a summary of some of the things to consider:
Were you practising excessively, with insufficient breaks?
Were you playing challenging pieces from cold?
Can you notice any muscular imbalances eg high or low wrist, high shoulders, elbows pulled in or out?
Do you hold excessive tension in your shoulders, arms, elbows, wrist or hand?
Do you play with high, curved fingers?
Do you push into the keys with force rather than releasing into the keys using gravity?
Does your hand and wrist tense up when you open the hand towards a wide stretch?
Do you hold non-playing fingers tense?
Are there are other activities which may have contributed: gardening, heavy lifting, texting, typing?
If you are in acute pain, you may be advised to rest completely initially, to allow some time for any inflammation to settle and for the tissue to heal. A splint or support bandage may be recommended initially to avoid excessive movement and help the tendons rest. Ice may be advised for inflammation, and perhaps some anti-inflammatory tablets or creams.
See Recovering from injury for further advice on rest, ice and elevation.
Exercises for recovery
It is important to allow sufficient time for tissue to heal before resuming regular playing. See Recovery from injury for general advice on all aspects of recovery.
Passive stretching exercises
When a hand or arm has been injured, the muscles tend to lose some of their elasticity. There is evidence to show that it is not helpful for anyone with tendonitis to rest completely. Scar tissue may form which can result in a chronic shortening of the muscle or tendon. Some gentle exercises will help to keep the muscles and tendons ‘elastic’.
However, many of the pianists I see say that stretching exercises that have been recommended to them are too extreme and tend to exacerbate their problem. I have therefore devised my own ‘passive stretching exercises’ which aim to release tension and keep the muscles toned without overstraining the affected areas. I suggest you start with just one or two, then include further exercises when you feel more resilient.
All these exercises will shortly be shown in more detail, with video, on the Online Academy.
‘Roskell Warm-ups and shoulder releasing sequence’ (see Yoga for Musicians DVD and Online Academy) These exercises release tension in the shoulder, arms and hands, and bring a strong blood supply to the affected area to assist in healing. In the case of shoulder pain, the exercises can be done with smaller movements.
‘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 wrist or elbow. Stay below your pain threshold. Then move each finger and thumb in all directions without tension.
The ‘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, giving a gentle stretch to the flexor and extensor muscles whilst keeping the wrist and elbow soft.
‘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.
‘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 aim to release any tension in the wrist or forearm. Do each stretch in time with your breathing – always breathing out and releasing into the stretch.
If you have been playing for a long time with tension, excessive force and muscular imbalance, then it may be time to think about changing some aspects of your technique. This is much easier to do than you may think, and it will not only ease the tension and pain, but your playing will also feel more effortless and the sound will be more beautiful. Most types of arm pain are linked to forearm tension (co-contraction) in some way, and to clenching the wrist and elbow tightly. The hand and finger need to release effortlessly downwards towards the keybed, with minimum pressure.
Also reflect on other activities which may be exacerbating the problem, and consider how to reduce tension, minimise force and address any muscular imbalances. Do any heavy lifting with the other hand. However, do be careful not to overuse the other hand to the point where you develop difficulties in that hand also.
If you have pain when typing, you may consider purchasing a lighter touch keyboard and an ergonomic mouse or trackpad. Check your posture – the forearm roughly level with the ground, the wrist flat and the elbow hanging loosely. When typing keep the arm relaxed but in movement as you move from key to key. Perhaps use a wrist support to rest your hand inbetween typing.
The Online Academy will shortly feature a more extended version of this article, with videos.
The Complete Pianist
There are many exercises in The Complete Pianist which help release tension in the forearm and aid recovery. The most important are:
The Roskell warm-ups and shoulder releasing exercises and Sitting Posture (both currently available on the Online Academy and the Yoga for Musicians DVD
The chapters on the wrist, shoulder, thumb and elbow may have particular relevance depending on the type of injury.
Elongating and releasing - helps to avoid co-contraction.
The pianist’s hand and finger: minimising the stretch.
The Parachute touch, an extension of the ‘Floppy forearm’ exercises, is fundamental to healthy playing.
The Nimble finger touch and the Singing finger touch - use the intrinsic hand muscles in place of forearm muscles.
The released hand and finger and Note endings - minimise lifting of the finger.
Rotation technique – if done correctly, rotation movements release tension in the forearm.
Arm release in chords – makes chord playing feel effortless.
A more extended version of this page, including videos, will shortly be available on the Online Academy