Golfers’ elbow: Medial epicondylitis
‘Golfers’ Elbow’ is characterized by pain and tenderness on the inside of the elbow at a point called the medial epicondyle, hence its medical term Medial Epicondylitis. Pain can also spread into the upper or lower arm. The tendons which are attached to the flexor muscles originate from the medial epicondyle, and ‘Golfers’ elbow’ can be associated with overuse of the flexors (excessive curling of the two end finger joints - the DIPs and PIPs - which are activated by the flexor muscles).
Pianists with golfers’ elbow may also experience weakness in the forearm, particularly in flexing the wrist or fingers, and difficulty in fully straightening the arm. Pianists with perceived weakness may try to overcompensate for the weakness by bracing the elbow to produce a louder sound, which further exacerbates the problem.
Medial epicondylitis can also be linked with tension and pain in the biceps.
Causes and triggers
Playing-related Golfers’ elbow may either develop gradually from prolonged practice or be triggered by a sudden increase in playing time and intensity. It may be exacerbated by other repetitive or percussive activities (such as playing golf), or excessive flexing (bending) of the wrist. It is also related to excessive tension in the elbow, forearm and upper arm.
Pianistically, the main contributing factors are likely to be a combination of:
Tension (‘grip’) in the elbow whilst playing piano, especially when playing forte.
Regular gripping (or curling) action of the fingers from the PIP and DIP joints (the two end joints).
Over-flexing of the wrist (playing with a high wrist).
Rotating from a tense elbow.
Repeated impact against the keys (such as playing repeated chords or octaves with a tense arm).
Added to this, a pianist may already have poor posture, rounded or tight shoulders or faulty alignment of the forearm, all of which may contribute to arm tension and 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. An initial period of rest will probably be recommended, followed by some massage, physiotherapy or osteopathic exercises to rebalance the muscles.
Other treatments that may be recommended by your doctor might include:
A brace, bandage or splint will minimise movement and encourage rest for the first few days.
Ice to reduce inflammation
Elevation: lifting the elbow above heart-level will help to reduce swelling.
Manual therapy such as massage or manipulation
Surgery would only normally be considered if the pain is severe and long-lasting, and other options have been fully explored.
Other treatments that have been reported by some as beneficial, but need further research and investigation include acupuncture, trigger point/myofascial release, ultrasound or shockwave therapy.
It is important to discuss the pros and cons for any of these treatments with your clinician before agreeing to treatment.
Exercises for golfers’ elbow
My experience is that once pianists learn to release the tension in the elbow, the whole arm starts to co-ordinate with greater ease, the sound improves and the pain starts to dissipate.
It may be beneficial to start by reassessing your overall sitting posture (See Penelope Roskell’s 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.
Roskell ‘Passive stretching exercises’
When a hand or arm has been injured, the muscles tend to lose some of their elasticity. My ‘passive stretching exercises’, below, 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.
Roskell warming-up and shoulder releasing sequence (See the Yoga for Musicians DVD and the Online Academy). This helps the healing process by releasing tension in the shoulder, which brings blood to the elbow area, while allowing the elbow to rest as much as possible. Practise this sequence regularly, staying below your pain threshold, focussing on keeping the elbow relaxed throughout.
‘Released arm’ Place your hand in playing position on a flat surface. Lower the wrist and elbow very gently, then raise them. Keep the arm very floppy and keep the elbow soft throughout. This is developed further in The Parachute touch.
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 in a flowing motion, keeping the wrist and elbow soft.
‘Elastic elbow’ Place your hands lightly on the closed fallboard of the piano. ‘Dust the wood’ by sliding your hands very lightly out towards the extremes of the keyboard, forward and back and in a circular motion. Open up the elbow joint to allow the arm to 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 elbow completely relaxed.
Do each movement in time with your breath – always breathing out into the stretch. Release into the stretch in a flowing gesture without bracing the elbow.
Roskell piano exercises for golfers’ 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. (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: healthy technique to natural artistry’ by Penelope Roskell
There are numerous exercises in The Complete Pianist which can be of benefit to pianists with golfers’ elbow, the most important of which are:
The chapter on The Pianist’s elbow
The Parachute touch
The Singing finger touch
Evenly curved fingers
The Elastic elbow and Dusting the keys
The neutral wrist
The Swan landing
Puppet on a string
The above exercises all help to rebalance the muscles, by reducing effort by the forearm flexor muscles, and using instead the intrinsic hand muscles as well as the stronger muscles of the back and shoulders. They 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 chords without clenching the elbow. The chapters on The Parachute touch in chord playing, Full arm release and Upward movements 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, writing, 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 help you learn how to avoid clenching the elbow in your other activities.