Overcoming Piano Related Pain: Finger, Wrist And Elbow Injuries (RSIs) — The Missing Link

Is there anything worse than being injured from playing your piano? – Especially if you’re a professional musician!?

Maybe you’re just beginning to experience pain in your fingers, wrists or elbows and are starting to worry about whether you have an injury – Especially a tendon injury…

If so, you’re also probably struggling with the question of whether you need to stop playing (not necessarily) – And how you’re going to pay the bills if you do have to stop…

Even if playing the piano is more of a hobby and not your profession, (and you’re not as stressed out about the pain) – It can still suck the joy out of playing, can’t it?

So, in the spirit of helping you figure this out and find the right treatment path and strategy…

Here are the questions and topics we’re going to cover in this article:

Outline / Table Of Contents

You can skip to any section using the links below:

• Can you get Tennis or Golfer’s Elbow from playing piano? — Tennis Elbow?
• The truth about “Tendonitis” / inflammation — Tendonitis Truth
• The myth of “Total Rest” — Rest Myth
• The missing link in piano RSI treatment — Missing Link
• The conventional treatment approach — Standard Approach
• A better treatment strategy — Better Approach
• Optimizing technique and posture — Piano Technique

Podcast Episode

Here’s the podcast version, (which contains all the audio from the video.) Play OR download for later – and please subscribe via the links below.

Hand, wrist & elbow RSIs / Tendinitis are epidemic among pianists – but can be overcome with the right treatment

Can You Get Golfer’s Or Tennis Elbow From Playing The Piano?

Piano-related pain can appear in many different places, including your back and neck, shoulders, elbows, forearms, wrists, fingers and thumbs.

Your elbows may seem like an odd place to hurt, but keep in mind that most of the muscles that act on your wrist and fingers have their origins (Origin Tendons) at your inner and outer elbows.

Which does put pianists and keyboard players at risk for Tennis and Golfer’s Elbow.

(Although, guitarists probably suffer these injuries even more! Article on ‘Guitar Elbow’)

Pianists are all-too-often afflicted with Carpal Tunnel Syndrome, as well, which we’ll cover but, first…

Inner Elbow Pain = Golfer’s Elbow / Medial Epicondylitis – Pain at or just below the little bony knob at the inner elbow often turns out to be Golfer’s Elbow

Outer Elbow Pain = Tennis Elbow / Lateral Epicondylitis – Pain at or just below the little bony knob at the outer elbow often turns out to be Tennis Elbow Elbow

These two injuries, along with ‘Carpal Tunnel Syndrome’ (CTS) and painful wrist, finger and thumb tendon problems fall into the category of ‘Repetitive Strain Injuries’ (RSIs) as you may know.

(Not to dismiss shoulder / Rotator Cuff injuries and back and neck pain among pianists, just that this website focuses on issues from the elbow to the hand.)

Unfortunately, these vexing tendon conditions can sometimes (often?) be more difficult to recover from than acute injuries. (Sudden, traumatic injuries, like fractures.)

This has a lot to do with the nature of tendons and tendon injuries, including the fact that:

Tendons are notorious for not healing easily or well.

Tendons often need a great deal of “encouragement” and can’t just be left alone and expected to heal (more about the “rest myth” coming up.)

The Truth About “Tendonitis” And Inflammation

There are a lot of myths and a great deal of misunderstanding about the true nature of many, if not most, chronic tendon conditions – In fact…

They’re NOT usually Tendonitis – The truth is that most chronic tendon conditions are not inflammatory in nature – Which is what the ITIS suffix suggests.

It’s usually TendinOSIS – Most chronic tendon conditions are degenerative in nature. The OSIS suggesting degeneration rather than inflammation (which is worse, unfortunately.)

Not that there’s no such thing as an inflammatory tendon injury / Tendonitis at all.

There is – and some tendon injuries may start out that way – BUT…

When it’s been going on for months, chances are, the inflammation is largely gone, your tendon still hasn’t healed and the process of degeneration is what’s causing your pain.

Essentially, degeneration means there’s a gradual breakdown process happening and ones body isn’t keeping up with the repair (regeneration.)

So, rather than a hot, swollen “excessive” inflammatory process, imagine something more akin to rot or decay in order to accurately picture degeneration.

The Myth Of “Total Rest”

If you’ve been advised by professionals or fellow musicians or convinced by what you’ve read online that you have to completely stop playing your piano (or other instrument, like your guitar) and rest in order to heal and recover, I have some good news for you…

That may not be necessary. “Total Rest” is not necessarily going to help your tendons heal.

The ‘Resting, Hoping And Waiting Fallacy’ is what I call it.

And stopping as much movement as possible is not necessarily going to have any effect on reversing that degeneration.

The key has to do with breaking the cycle of stagnation and stimulating healing/regeneration, and this requires a much more active approach.

(Which is not to say that I have all the answers, just a more accurate assessment of the problem – and a more sensible treatment strategy.)

The Missing Link In Treating Piano RSIs

One of the most insidious, underlying causes of these RSIs that malign so many musicians is a little-known issue in the tissue. (It’s something that’s not well known in medicine, anyway.)

‘Ahesions’

Adhesions are exactly what they sound like: areas of tissue that have become stuck together.

It’s a necessary property of the Collagen (protein) that the majority of your tissues are composed of.

Collagen has to be able to bind to itself in order to form complex structures, like ligaments, fascia, tendons and cartilage.

And when there’s either an Acute Injury to your tissues – OR a sustained / chronic period of friction, irritation and/or compression of your tissues, you get adhesions.

AKA: ‘Scar Tissue’

You get a lot of Scar Tissue quickly when you sustain an Acute Injury, like a tear…

Your body has to “fill in, secure and mend” the torn area quickly!

And you can very easily feel the difference before and after the injury: The area becomes much more restricted because the scarring and repairing process is rather haphazard and excessive; it’s often “overkill.”

The process of ahesion formation is very gradual, however, usually happening at a snail’s pace, and going unnoticed until it has accumulated significantly and starts to produce symptoms.

And it can produce a range of symptoms, like:

• Joint stiffness,
• Loss of flexibility,
• Muscle fatigue, and, of course
• Tendon pain

(The terms adhesion and scar tissue are often used interchangeably but I think that even though they’re made of the same stuff the distinction is useful, because they form very differently.)

Where This Impacts Pianists The Most

Pianists (and to a similar extent many musicians, including guitar players) have to perform a great deal of finger motions in order to play the piano.

The vast majority of the finger and thumb muscles are found in the forearm, and they act on the fingers by way of long tendon “cables.”

And these long tendons of the wrist and fingers have an additional anatomical component that most tendons don’t:

Synovial Sheaths

The ‘Synovial Sheaths’ serve to cushion and protect these tendons as they pass over either side of the wrist, where they’re subject to more potential friction.

And these sheaths are filled with the same fluid that’s found inside your joints: ‘Synovial Fluid’ – Hence the name: Synovial Sheaths.

The problem is that due to thousands of cumulative motions, and other factors, like excessive tension, fatigue and poor piano technique…

Adhesions begin to form between the tendons and their sheaths (and often deep in the muscular layers themselves.)

(Stress, poor diet, drug and alcohol use, and lack of exercise and hydration may also play a roll.)

A few adhesions here and there in the body is not a big deal, but when they’re accumulating in your finger tendon synovial sheaths, you may develop…

Tenosynovitis

‘Tenosynovitis’ is what it may be called if it’s the primary issue, anyway.

The ITIS suffix, suggesting an inflammatory process, which may be occurring – especially in the early stages of the RSI, in some cases.

(This is what they diagnosed me with nearly 30 years ago, and what seems to have led me down this path of specializing in helping people with this and similar RSIs, like Golfer’s and Tennis Elbow.)

However, this ITIS / inflammation assumption may be just that: An assumption – which turns out to be wrong – especially in the long run.

Looking back, I don’t believe I had any significant inflammation in my Wrist Extensor Tendons…

But I did have a great deal of tension and adhesions in those tendons and their muscles (and #@*% pain!) that I was completely ignorant about how to treat at the time.

I was just getting started in my field of Bodywork and Massage Therapy – (which was how I injured myself, not playing the piano) – and I didn’t have the techniques I later learned that were so efficient at releasing ahesions.

Carpal Tunnel Syndrome

CTS can be the consequence if this dysfunctional dynamic happens in the Finger Flexor Tendons as they pass through the Carpal Tunnel at the palm side of the wrist.

This is the most serious manifestation of these kinds of tendon problems, because as the friction builds up in tendons and their sheaths and they start to swell…

There’s not enough room to accommodate much of that swelling. Space is very limited in the Carpal Tunnel.

(Swelling is more of an active inflammatory process, by the way.)

And when the increasing pressure reaches a certain threshold it begins to deprive the nearby Median Nerve (also in the tunnel) of it’s critical oxygen supply.

One then develops the tell-tale symptoms of CTS: Numbness, tingling and/or pain in the thumb, index and ring fingers and dramatically declining grip strength.

DeQuervain’s Tenosynovitis

‘DeQuervain’s Tenosynovitis’ affecting the thumb, is another manifestation of Synovial Sheath adhesion, irritation and pain.

This is much less serious, though, since there’s no risk of a serious nerve entrapment dysfunction on this side of the wrist.

(Although, it’s not uncommon for one to have a nerve entrapment of the Radial Nerve “upstream” near the outer elbow, which exacerbates ones DeQuervain’s symptoms “downstream.”)

The Standard, Symptom-Centric Approach

Whether we’re taking about Tenosynovitis of the Finger Extensors on the back side of the wrist or the Flexors on the palm side (which can snowball into CTS) OR Golfer’s Elbow / Tennis Elbow…

The standard treatment approach unfortunately focuses on the acute symptoms (pain etc.) rather than the chronic causes (adhesion buildup, chronically shortened, weakened muscles, etc.)

I call this convention / Allopathic strategy “The S.I.C.K. Approach”

• Suppress symptoms – Pain and inflammation
• Immobilize – Via braces and splints
• Cool – To “reduce” inflammation and swelling

(Perhaps the “K” should stand for “Kills your chance of healing in a timely manner!)

Yes, this approach will tend to reduce your symptoms! (Temporarily, anyway.)

But is mere temporary relief really your goal?

What “manages” (suppresses) symptoms and what supports your healing process are two completely different things.

In short, inflammation IS a stage of your healing process and not the real problem – Here’s more on inflammation

Immobilizing these kinds of injuries does not help them heal – Here’s why supports are not the answer

Icing the heck out of your poor tendons doesn’t help ether – Why icing is not a good idea

And the last thing you want is your tendons injected with Cortisone! – Why Cortisone’s so bad

We could also talk about topical remedies (neither good nor bad) – Thoughts on lotions

A Better Treatment Approach For These RSIs

A better approach involves:

• Using heat (or at least avoiding ice)
  
  
• Allowing symptoms, especially inflammation – (Again, it’s part of your healing process.)
  
  
• And mobilizing the area – especially with Massage Therapy or self-massage techniques and stretching.

#1 priority: Releasing Adhesions – The goal is that with the right approach, your tendons can be freed to slide more easily in their sheaths

And your chronic tension and adhesion-restricted muscles can be released.

#2 priority: Stimulating tendons – What this comes down to is strategically “bothering” the tendons with the right amount of friction to break the cycle of stagnation.

Tendons, once again, have this nasty habit of not healing well and slipping into a state of stagnation and degeneration.

Newer medical interventions acknowledge and attempt to address this through techniques like Platelet Rich Plasma Injection Therapy.

I don’t believe its necessary (or such a great idea) to go to such invasive extremes to accomplish this, however.

I’ve been getting great results for years working on tendons by hand and teaching people Self-Massage Techniques to use a home.

The bottom line is that…

More circulation and metabolic activity needs to be stimulated in and around the tendon…

Rather than suppressing circulation and inflammation and allowing the decay of stagnation and degeneration to continue to weaken it!

Will any massage technique help? Many kinds of hands on manipulation may be beneficial.

However, freeing up dense sticky adhesions is not the easiest thing to accomplish, in all honesty.

Merely pressing (with hands or tools), rubbing, rolling (with foam rollers, etc.) and kneading tissues can be terribly inefficient.

There are countless videos out there showing you all manner of techniques, which may be good for reducing tension and good for overall muscle health – but…

May not get the adhesion-release job done!

It requires a trifecta of pressure, friction and tension – in the right combination.

And the good news is that this is something you can learn to do yourself at home.

Should you seek out a professional for help as well? Absolutely!

But, finding the right practitioner is not always easy (and it is usually expensive.)

And although most musicians probably can’t afford to see a therapist several times a week, you can work on yourself every single day for free.

Optimizing Piano Technique

There does seem to be a dearth of instruction when it comes to teaching optimal posture and piano technique; the “biomechanics or Ergonomics of piano,” if we’re getting technical.

In this TEDx video talk, Dr. Barbara Lister-Sink, internationally acclaimed pianist and teacher, gives a sobering presentation about pianists and their terrible propensity for career-ending injuries and pain.

“Thousands of serious pianists worldwide are suffering unnecessarily, and with little hope of finding adequate help.”

• “26-93% of pianists report injuries” – (2005 study of literature)
• “Injuries in 77% of female pianists” – (2006 Japanese study)
• “Injuries in 72% of professional pianists” – (2010 Australian study)

Dr. Barbara Lister-Sink (In video above.) Pianists, Proceed at Your Own Peril

If you’re going to be sitting and playing the piano for hours at a time, it would be a very good idea to try and optimize your posture and use the piano technique that’s the easiest on your body.

(This may be directed more at the hobby pianist rather that the professional musician, but according to Dr. Barbara Lister-Sink in the video above, this seems to be lacking across the board!)

Here are some resources to get you started in the right direction if you’re just starting to work on optimizing your posture and technique.

YouTube Playlist On Piano Technique:

Tips from Pianist Magazine, Josh Wright, Andy Grall, Weekly Piano and Jonathan Kuttner on “avoiding tension in your playing,” “developing ease and relaxation,” “the wrist as the 4th joint” and “avoiding Tendinitis and other RSIs”

Articles On Piano Injury Prevention

• The Healthy (& Happy) Pianist: A Guide to Stress & Injury Prevention
• Pianists Pain-Prevention Tips (by Howard B. Richman)
• Preventing and Resolving Piano Injury

More to follow soon…

AND if you need some help putting together a self-help plan, you’re certainly in the right place!

Just follow one of the links below, depending on whether you have Tennis or Golfer’s Elbow.

If you have Wrist or Finger Extensor Tendon Injury / Tenosynovitis, pick the Tennis Elbow program.

And if you have a Wrist or Finger Flexor Tendon issue, pick the Golfer’s Elbow program. (This program might be useful in the case of CTS but it’s not really designed to address CTS.)

Learn To Treat And Heal Your Own Tennis Elbow, Golfer’s Elbow, Wrist Or Finger Tendinosis

You’ll get instant access to a complete VIDEO program designed by a professional therapist to help you take charge and break your vicious cycle of pain and frustration!…

I’ll be your personal tutor guiding you through step-by-step video lessons, where you’ll get the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home. (Without any special equipment.)

Tennis Elbow sufferers: Learn more about the home program here

Golfer’s Elbow sufferers: Learn more about the home program here