Common Peripheral Nerve Injuries for Musicians

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According to neurologist R. Lederman, peripheral nerve injury (neuropathy) accounts for 20% of all diagnoses in musician patients. The most frequently encountered neuropathies are listed in Table 1.

Main injuries to peripheral nerves suffered by musicians (Based on 1353 musician patients assessed by R. Lederman) • Thoracic outlet syndrome: 22% • Ulnar neuropathy at the elbow: 21% • Carpal tunnel syndrome: 18% • Cervical radiculopathy: 9%

Nerve injury predictably occurs at a point on the body where a nerve is subjected to compression, friction, or stretching. Compression may be caused by a bone, ligament, muscle, tendon, or a thickening of the fascia. A superficial nerve may also be compressed from outside the body. According to Lederman, there is no evidence to suggest that instrumental musicians are more likely than other professionals to develop neuropathy. However, it can be clearly shown that compression neuropathies are diagnosed in many instrumentalists.

After practising his instrument for a while, a 24-year old violinist suffers from pain and paresthesia (numbness, tingling) in the middle of his left forearm and in his left hand, forcing him to stop playing. The symptoms described by the musician suggest two possible diagnoses, either thoracic outlet syndrome or ulnar neuropathy at the elbow. Again according to Lederman, the most common neuropathy of musicians is symptomatic thoracic outlet syndrome.

String players (45% of patients, mainly in the left arm), keyboard players (25%, bilateral injury), and woodwind instrumentalists (17%) are most often affected by thoracic outlet syndrome. About half of the patients suffering from this syndrome have a visible shoulder-girdle depression, which increases the proximal tension on the brachial plexus at the root of the arm’s peripheral nerves (see Photos 1-2). Severe neuropathy with a nerve conduction deficit, however, rarely occurs in musicians (Lederman).

Summary of symptoms of thoracic outlet syndrome (No nerve conduction deficit, even in its symptomatic form) • Localized forearm pain, more often on the ulnar (internal) side than on the radial (external) side • Sensitivity, including numbness, paresthesia (tingling), burning, or a swelling sensation in the same area • Symptoms associated with certain positions or postures, especially when the upper limb is raised above the shoulder Summary of symptoms of ulnar neuropathy at the elbow • Pain reported at the elbow and usually on the ulnar side of the forearm, hand, and fourth to fifth fingers • Elbow painful to the touch • Paresthesia (tingling) is less common, but a loss of sensitivity may occur on the ulnar side of the forearm, hand, and fourth to fifth fingers.

The second possible diagnosis is ulnar neuropathy at the elbow. A common pathogenic mechanism is intermittent nerve friction, which occurs when the nerve becomes trapped at one or more points along its pathway, impeding the sliding motion of the arm. Among string players assessed by Lederman, 90% had injuries to the left arm / left hand. He hypothesizes that keeping the left elbow bent to hold the instrument creates and maintains a pressure point on the ulnar nerve. The steady pressure affects the left nerve more than the right nerve is affected by the repeated flexion-extension of the right elbow moving the bow.

Isabelle Duchesne, B.Sc., PT, FCAMT, Bachelor of Music (classical piano) is a physiotherapist at Kinatex Sports Physio, Rosemount and Downtown Montreal, who has treated professional musicians for several years. She is a Fellow of the Canadian Academy of Manipulative Physiotherapy, presently studying for the European Diploma of Arts Medicine (Paris).

References
Lederman R. Neuromuscular and musculoskeletal problems in instrumental musicians. Muscle Nerve 2003; 27:549-561.
Lederman R. Focal peripheral neuropathies in instrumental musicians. Phys Med Rehabil Clin N Am 2006; 761-779.

Translation: Lynn Travers