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Sore Points

John Robert Brown

'My hand is born to me,' said Vladimir Horowitz. 'Why compare? You cannot be jealous of my hands. That's a waste of time.' Dissatisfaction with physique may be a waste of time according to the great pianist, quoted in David Dubai's Evenings With Horowitz, but physiological deficiencies and difficulties are the professional interest of Howard Bird, professor of pharmacological rheumatology at Leeds University. A pianist himself, Professor Bird has sufficient musical competence to have worked seriously at most of the Beethoven sonatas. He combines his two specialisms to help musicians.

First some definitions: 'Tenosynovitis simply means inflammation of the synovial sheath through which a tendon runs,' says Bird. 'The tendons are the distal extensions of the muscles. Tenosynovitis literally means that you've got inflammation of one of those tendons. But with musicians it's unusual to get tenosynovitis across all fingers. In string players, the arms do completely different things. In the woodwind players, one thumb takes the weight of the clarinet. Keyboard players tend to get more diffuse involvement of all tendons.

'Epicondylitis is a problem affecting the other end of those muscles in the forearm, going distally into tendons that move the fingers These muscles are fixed at the bone of the elbow at a place called the epicondyle. You have two, the outer side of the elbow known as the lateral epicondyle and the medial epicondyle (the funny bone on the inside of the elbow). There is one group of muscles attached there. Epicondylitis is inflammation of the point where the muscle goes down into a single ligament and joins the epicondyle. You can have a lateral epicondylitis, which is popularly called tennis elbow, and medial epicondylitis, which is called golfer's elbow.

'Because there's also a certain amount of rotation at the elbow, the typical ergonomic problem that causes epicondylitis is a twisting movement, perhaps with the hands holding something. People who get it very commonly are those using screwdrivers. That occurs in certain piano passages where you are rolling octaves. But on the whole it's not too common in musicians.

'You get it in string players in their bowing arm. Sometimes it's related to disease. It's common in diabetics If you have widespread use of the shoulders in all arcs of movement, a frozen occasionally occurs in double bass players with their bowing arms. It's less common in the violin players, because they are not reaching so much.

'The other discrete entity is carpal tunnel syndrome. The movement of the muscles and tendons is dependent upon the nerves supplying those muscles. There's a network of nerves, radiating out to each part of the skin. Those nerves tend to be protected when they go over exposed surfaces, by being buried in canals. One of the principal nerves that supplies the hand, the underside of the hand, thumb, first two fingers and half of the next one, has to traverse the wrist, where it's vulnerable. The median nerve traverses the inside of the wrist, in a tunnel called the carpal tunnel. Normally it's a snug fit, but if something else is competing for space in that tunnel, if there's pressure, then the nerve gets squeezed. Then it causes symptoms of pins and needles, and ultimately you lose the power of the muscles.

'These are all discrete things, where we can say exactly what's going on and for which there are specific treatments. For example, we can do a small operation to release the median nerve in the carpal tunnel, or put an injection of steroids to reduce local swelling. It's a temporary thing, and it can be a cure if you get them in the first four or five days.

'So-called RSI or work-related upper-limb disorder is more diffuse. You don't have the physical signs of abnormality in these specific places. But there's no doubt that a certain number of people who do repetitive action get a bit of swelling forearm pain, and we don't know why. There are some theories.'

Repetitive and forceful movements can be a source of problems. Bird says that musicians may cope over many years, because of their training, but then, 'something may just tip you over. So that the force that you are exerting, and the frequency and the rapidity of the action, are factors.

'As a student I learned most of the Beethoven piano sonatas. They are all quite different. I just got aches and pains coming on with certain passages. I don't have problems with Mozart because I have slightly small hands. Mozart is suited to small hands. I have some problems stretching in Brahms; the stretching in Rachmaninov I find problematic. So different styles of composition have different technical requirements.'

Can problems arise due to over-practising? 'Just the total amount of playing isn't always critical. I'm sure that if I played the same Beethoven sonata - one that doesn't cause me any problems whatever - over and over again, I wouldn't have any problems. It's only introducing certain technical moves that tend to cause the problem.

'Hyperlaxity [an unusually large range of movement] is another factor reflected in the joints and the structure you are born with. Natural people, before they've got arthritis, have a completely different range of movement at a main joint. Some people are very supple, some people are always quite stiff. Stiffness is a bit more common in diabetics and more common in heavy smokers. We don't know why.

'It's quite clear that what Rachmaninov composed, he was going to play himself. So you've got an idea of what his hands could do. There's no doubt that he, and Liszt, had very large hands. Paganani had very supple hands. It was amazing what he could do. I think his fingers could curl right back, almost to his forearm!'

Bird says that there is now greater awareness of the problems and dangers. 'It has become more important in this country in the last ten or twenty years, with the setting up of the British Association for Performing Arts Medicine, which was originally designed just to treat injured musicians, but inevitably does (or should have) a preventative or protective role. The Dutch have led the way in this: they are probably 20 or 30 years ahead. There's a doctor attached to each orchestra, and to specialist institutions. The Dutch musculo-skeletal physicians go into music colleges and schools and advise. We are moving in that direction. The British Association for Performing Arts Medicine has advertised for, and interviewed, local GPs. They tend to be attached to an orchestra, voluntarily.

'Although I'm university employed and not in private practice, we do try to offer a service for musicians who are referred by their GP. There is a group in London, all retired, pretty experienced, who give up one day a week of their spare time to see musicians. I think the first appointment is free. I'm happy to see people, my service is not as good as it might be, because I'm quite overloaded.'

Faced with the onset of problems, what can the individual musician do?

'I think to say "rest completely" is a bit nihilistic,' says Bird. 'Quite often the problem is only experienced in one bit of one movement. So, rather than complete rest, the remedy is to take the movement out of the repertoire for a week, the re-introduce it gradually, and in instalments, to see how you go. If you are really stuck, change to a different piece. In general, the longer it's been going on, the harder it is to get back to normal. Taking early advice, and taking avoiding action, is the answer.'

Or pianists could consider Josef Hofman's eccentric solution to having small hands, His 'avoiding action' was to have Steinway build him a piano which squeezed the octave into the space of seven keys.

First published in Classical Music magazine, 17th January 2004. Used by kind permission. Not to be reproduced without permission.
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