Thumb pain and Tenosynovitis
There are various kinds of thumb pain which can affect pianists and other keyboard players. In this page I focus on Tenosynovitis (also known as De Quervain’s tendinopathy or tendinitis of the thumb). Some of the exercises described here may also be of benefit for pianists with other conditions caused by stresses on the thumb tissue.
Tenosynovitis is a painful condition caused by inflammation of the tendon sheath, which is rubbed against by the tendon which slides through the sheath. The pain may be localised in the inner side of the wrist at the base of the thumb, or may spread more widely. Pianists may experience a shooting pain down the thumb on impact with the keys, or a more generalised ache.
Finkelstein’s test is a simple diagnostic technique that you can do yourself: curl your thumb and tuck it under your palm, wrap your fingers around it, then swivel your wrist to pull the hand in the direction of the fifth finger. If you feel pain where the thumb joins the wrist, then you may have De Quervain’s tenosynovitis.
Pianists with tenosynovitis are most likely to experience pain when playing at full stretch, especially when playing forte, or when passing the thumb under the hand in scalic passages. Pianists with small to medium sized hands are more likely to experience Dr Quervain’s tendinopathy because the thumb is more frequently being held out at full stretch. Pianists with small hands and chronic tenosynovitis may consider looking into purchasing a smaller-sized keyboard.
Please see Recovering from injury and Forearm and hand pain for general advice on recovery. It is very important to get an accurate diagnosis, ideally from a medical specialist who has experience of working with musicians. Doctors normally recommend rest, ice and elevation at the initial stage, which aims to reduce swelling and inflammation.
Rest: (for the first two or three days at least) is needed to give the tissue time to heal. A bandage or splint can be used to immobilise the thumb.
Ice: reduces pain and inflammation. Apply an ice pack (or a pack of frozen peas wrapped in a towel) to the affected area for 5-10 minutes several times a day.
Elevation: of the arm above heart level drains any excess fluid away from the affected area to reduce swelling.
A couple of days rest may be all that is needed. However, if the pain does not go away then seek specialist medical help and talk to an experienced piano teacher The sooner the problem is diagnosed and treated, the quicker the recovery. Your doctor may advise you to stop playing initially, or to reduce playing to the level at which the pain is no longer experienced. He may also prescribe painkillers or anti-inflammatories to reduce inflammation and pain.
During the initial rest period, it is important to consider whether the problem is playing-related or was triggered mainly by other activities.
Were you playing particularly challenging repertoire, perhaps with wide stretches and repetition at the stretch?
Were you applying a great deal of force to the thumb?
Were you holding the thumb rigid?
Do you also have pain in your forearm?
Are your wrist and elbow tense?
Were you under emotional or mental stress which was causing tension? Were you working to a deadline, and practising harder than normal?
Were you also using your thumb a great deal in other activities such as typing or texting, or do you tense the thumb when driving or playing sports?
Please note that tenosynovitis sometimes occurs during pregnancy but usually resolves itself gradually after birth.
Revising your technique
During the rest period, much valuable work can be done to develop a healthier approach to technique which will avoid recurrences in the future. Start initially by addressing aspects of technique in the healthy hand, and only incorporate the exercises into the affected hand once the pain has subsided. Whilst recovering you may need to play piano and avoid stretches altogether. If you have small hands especially, you may need to reconsider your repertoire and avoid dynamic pieces which stretch your hand to its limit.
Revising your technique
Below is a list of my exercises which I have found to be particularly helpful for pianists with tenosynovitis. They will all be described in more detail, with video, soon in The Complete Pianist and the Online Academy.
De Quervain’s tenosynovitis can be linked to muscular imbalances stemming from tension or imbalance in other parts of the body e.g. in the neck, back, shoulder, elbow or wrist. If you experience tension or pain in any of these areas, it is worth exploring exercises for releasing tension and rebalancing those areas (See Sitting posture in the Yoga for Musicians DVD or the Online Academy). Some help from an Alexander technique teacher may also be helpful.
Do regular warm-ups to bring an adequate blood supply to the thumb before playing. (See Roskell warm-ups in Yoga for Musicians DVD or the Online Academy)
Check the alignment of the hand with the forearm. If your forearm is generally in a straight line with your thumb or second finger when you play (in ‘ulnar deviation’), you will need to practise releasing and swivelling the wrist round so that the hand and arm are working around a more neutral alignment, with the third finger in line with the forearm. This is especially important when playing chords and octaves.
The cushioning wrist
When playing chords or octaves, particularly in forte, each repeated impact of the thumb as it plays the key will tend to exacerbate the pain, especially if the wrist is held tense. The impact of the hand on the key needs to be cushioned by flexibility in the wrist and the other joints. The Roskell Parachute touch teaches how to approach the keys with a released wrist.
Check whether you move the thumb independently from its base joint (CMC joint) or whether you just press the thumb down by using a movement of the whole arm. With your arm resting on the arm of a chair, move the thumb freely in all directions from its base joint near to the wrist without moving or tensing the rest of the hand or arm. Practise tapping the thumb lightly from the wrist then play some scales or other simple exercises, moving the thumb lightly from its base and keeping the hand calm.
Releasing the non-playing thumb
If you have a tendency to hold the thumb rigid, practise some scales very slowly, checking that the thumb has released all tension and is completely loose immediately after playing each note.
Releasing the stretch
Many pianists (especially pianists with small- to medium-sized hands) have a tendency to hold the hand at full stretch, with the thumb stuck out, even when it is not playing. It is very important to release the stretch and let the hand relax between chords of wide intervals (See ‘The Splay’).
Even pianists with healthy hands should avoid playing octaves for more than ten minutes at a time.
The Complete Pianist
There are many exercises in The Complete Pianist which are useful for pianists with thumb problems. The most important sections are:
The Pianists’ thumb
Opening the hand from the palm
Releasing the stretch
Releasing the non-playing fingers
Octaves and Widely spaced chords
Roskell warm-up and shoulder releasing sequence
Also reflect on other activities which may be exacerbating the problem, and consider how to reduce thumb activity and address any muscular imbalances. If you have pain when typing, you may consider purchasing an ergonomic mouse, using a trackpad or switching to the other hand. Use the other thumb for the space bar. Avoid texting - perhaps use voice recognition instead. Lift heavy objects with the other hand or use a wrist-thumb support. However, do be careful not to overuse the other thumb to the point where you develop difficulties in that hand also.
With the right support and with a certain amount of patience (injuries to tendons and tendon sheaths can take time), most pianists can recover completely and be able to resume normal playing, as long as the underlying causes have been sufficiently addressed. When the pain subsides, however, do resist going straight back into a busy playing schedule. Increase playing time very gradually (see Resuming playing in Recovering from injury) and start with gentler, less challenging pieces that do not involve big stretches. Consider how to revise your practice methods so that you take more frequent breaks.
A more extended version of this page, including videos, will shortly be available on the Online Academy