By Phil & Vivian Williams
Posted by permission
WHAT IS tendonitis?
Tendonitis is a problem always lurking around the corner for string musicians. It can strike when you least expect it. It is an inflammatory condition of a tendon, often at a joint, especially the wrist, knee, or elbow. It is caused by tearing and abrasions of a tendon due to overwork under conditions of high muscle stress. It is typically brought on by repeated controlled movements, and is an occupational hazard of musicians, typists, carpenters, assembly line workers, tennis players, and computer game nuts. “Tennis elbow”, “carpenter’s wrist”, “Atari wrist”, and carpal tunnel syndrome are common forms of tendonitis.
Both of us have experienced and lived with tendonitis as musicians. Phil had to have his right wrist operated on in 1983 for extensor tendonitis, and has been treated for tendonitis at the base of the right thumb. Vivian has been treated for rotator cuff tendonitis in her shoulder and has intermittent tendonitis problems with her right thumb and her left hand and wrist. The information given here is from personal experience and advice given to us by doctors and therapists. Anyone believing they may have tendonitis or experiencing the problems discussed below immediately should see a doctor familiar with tendonitis and its treatment and start the course of treatment recommended to them. Doctors with sports medicine experience often are knowledgeable about tendonitis problems. Sports and instrument playing both require lots of physical movement and conditioning and have similar muscle and tendon related problems.
There are different approaches to treatment ranging from rest and physical therapy to surgery. It can be useful to talk to people who have had or are undergoing treatment for tendonitis, to identify a medical practitioner with whom you can work.
Musicians often first experience tendonitis as a sharp pain located in one spot in the wrist, elbow, or base of the thumb. It is characterized by a burning pain, sometimes only when the affected part is moved in a certain way, or in more severe cases, continuous. Unlike simpler muscle strains, it tends to persist for a long period of time. If not taken care of right away, it can develop into a major problem involving months of intense pain and perhaps a total inability to play.
HOW TO PREVENT TENDONITIS
Warm up. Tendonitis can be avoided by warming up well before playing and by playing as relaxed as possible. Warm up for at least ten minutes prior to playing, and preferably for half an hour. The warm up is intended to get the tendons running smoothly and the muscles warm. It is not designed to build strength, so simple, non-stressful movements such as flexing the wrist, arm, and fingers are all that is needed. A light duty squeeze ball or exercise putty also works well as a part of the routine. Some musicians warm up with Chinese Iron Ball Factory exercise balls. Use simple exercises done on a regular basis to build up muscle strength for playing.
Grab a condensed soup can with your fingers, with the back of your hand up, and raise and lower it about 20 times a day using only your wrist. Do arm strengthening weight lifting with fairly light weights, like 3 or 4 pounds, on a regular basis each day. Just a few repeats of these exercises each day gradually builds the muscles and helps prevent playing problems. Going gung ho with lots of repeats can be harmful and result in the very condition you are trying to avoid.
If your fingers are cold before you have to play, immerse them in warm water to increase circulation and relax them. We know from experience that going from the cold outdoors in the winter to high intensity square dance playing with no chance to get warm can result in tendonitis problems. Phil had this happen to his right thumb from gripping the pick and playing the guitar.
Stretch. To help prevent wrist area tendonitis, stretch your fingers out as far and hard as you can, then stretch them a bit more, relax, and repeat a few times a day. Stretch your arms and shoulders before playing, when taking a break from playing, or any time you think about it.
Take breaks. Take frequent breaks when you’re playing. Don’t practice for hours at a time if you’re out of shape: build up to it. Vivian’s doctor told her of a violinist who habitually practiced 8 hours a day, and was unable to keep up this schedule for a few weeks. When she resumed her practice schedule all at once, she developed rotator cuff tendonitis in her left shoulder.
Guitar and mandolin players: Guitars, mandolins, and other fretted instrument played with a pick have high tendonitis potential. Watch how tightly you grip the pick. Too tight a grip can strain the thumb muscles, resulting in tendonitis in your right thumb. If you feel your wrist or arm start to tighten while playing, back off and try to find a way to keep playing with the muscles relaxed. There are many muscles in the arm and hand, and often you discover that you can use a set of muscles you have never before been aware of. A tight grip on the instrument’s neck with the left hand, and pushing down hard on the frets, especially for chords, also can result in muscle strain and accompanying tendonitis
Fiddle players: Fiddle playing also has great tendonitis potential. If you remember how awkward it felt to hold and play a fiddle when you were just beginning, you realize what an unnatural position it is for the human body to get into! Tendonitis in the left or right wrist and thumb, in the right elbow, and in the left shoulder are common problems for fiddlers. In most cases, these can be avoided or relieved by warming up and doing stretching and muscle toning exercises. If you haven’t played for several days, don’t start in by playing for hours all at once. Let your body break in gradually! If you start feeling discomfort, take a break as soon as you can.
Julie Lyons Lieberman has published two videos and a book about using your body correctly to play fiddle. The videos are The Instrumentalist’s Guide to Fitness, Health and Musicianship and The Violin In Motion: An Ergonomic Approach to Playing For All Levels and Styles, and the book is You Are Your Instrument: The Definitive Musician’s Guide to Practice and Performance.
Take aspirin. Vivian’s doctor made this recommendation, which seems to work: if you know you’re going to get into a situation, such as playing a dance, where you can’t take a break when you should, you might take an aspirin or other anti-inflammatory ahead of time, to ward off trouble. You might even try taking aspirin after the gig, even if you aren’t sore, because tendonitis often doesn’t show up for a couple of days.
HOW TO TREAT TENDONITIS
If you start feeling aches and pains, consult a doctor right away. DO NOT DELAY! The longer you wait, the worse the condition gets, the longer it takes to recover, and the less chance you have of making a complete recovery. Many doctors don’t know much about tendonitis, so find one who does. Standard treatments include rest, immobilization with a splint, ice, and anti-inflammatory drugs such as aspirin and ibuprofin. More drastic treatments include cortisone injections and surgery. Don’t let the doctor give you cortisone injections unless nothing else works and you’re desperate. Once your condition has been diagnosed, your doctor may or may not be able to give you significant relief, but there are lots of things you can do for yourself once you know what’s wrong.
Anti-inflammatory drugs. The simplest treatment is aspirin. Phil’s doctor had him taking two 325 mg. (5 grain) tablets every four hours day and night, and keeping it up for several weeks during the acute phase. At these doses, you should take the enteric coated aspirin that doesn’t dissolve until after it gets past your stomach, to avoid irritating the stomach lining. If the tendonitis really is acute, your doctor may have to treat it with special anti-inflammatory drugs to knock the inflammation down before beginning regular treatment.
Caution: Consult your doctor before taking this much aspirin. Make sure that you aren’t allergic to aspirin, or asthmatic, pregnant, taking other anti-inflammatory or blood-thinning medication, and that you do not have ulcers. If your ears start ringing or you start to get dizzy, cut down the dose until the side effects stop.
Ibuprofin (Motrin) will also cut down inflammation from tendonitis Acetaminophen (Tylenol) will not do the job, since it is just an analgesic (pain-killer), not an anti-inflammatory.
Caution: Don’t let your doctor give you stronger anti-inflammatory drugs unless your condition doesn’t respond to milder drugs, since many prescription drugs have severe side effects. And don’t let your doctor give you cortisone shots unless you really need them to knock out a bad inflammation, since they can actually damage muscle tissue.
Caution: Some powerful painkilling drugs may mislead you into thinking that you are cured and therefore you can resume normal activity. Phil had tendonitis in his wrist, and was prescribed drugs which effectively killed the pain, without also being given proper therapeutic treatment. As the pain levels were kept down, he continued to do things which further exacerbated the condition, eventually leading to a chronic tendonitis condition and surgery.
Ice. Another simple and effective treatment is the use of ice. Apply ice for five or ten minutes at a time wherever it hurts, especially after exercising the affected area. It may sound unpleasant, but it does relieve inflammation.
Friction Massage. An effective treatment which is more often known to physical therapists than to doctors is friction massage. Have a therapist or other experienced person show you how and where to do this. Basically, what you do is find the very sorest spot, dig in with your fingertips and rub across the tendon. It hurts like crazy at first, but feels better afterward. What it does is break up the scar tissue that is preventing the tendon from sliding smoothly along its sheath, and this allows proper healing. You might want to apply ice afterwards. Phil attributes his ability to play today without pain (most of the time) to learning how to do friction massage from a physical therapist who knew how to treat his condition, and using it when the hint of a recurrence is felt.
Rest, immobilization, and splints. The most effective treatment for tendonitis in the wrist or elbow involves reducing stress on the tendon by means of rest, immobilization, or the use of a splint. Splinting is a standard treatment for tendonitis in the wrist area. Sometimes the problem can be controlled simply by wearing a splint at night. In general, a useful rule to follow is “if it hurts, don’t do it”, or do it as little as possible, since continued exercise aggravates the condition. A drastic but relatively quick treatment is total immobilization of the affected joint with a cast. This is not always practical. You can get some of the same benefits by using a splint (possibly with a sling) part of the time. Splints are available at most drug stores, and custom splints can be made on order from your doctor.
Caution: If the tendonitis is in your shoulder, do not restrict the shoulder’s motion, as you can develop “frozen shoulder” which is much harder to deal with than tendonitis When Vivian developed tendonitis in her shoulder, her doctor warned her about this. However, she had been so traumatized by Phil’s recent tendonitis experience that she stopped moving her arm whenever it hurt, and sure enough, by the time the tendonitis was gone she could not raise her arm up above shoulder level. It took months of physical therapy to get the shoulder unfrozen. Although it may be painful, gentle stretching and reaching is not harmful and will help you maintain mobility in your shoulder.
Caution: If you try to rest the affected part by compensating with another part of your body, you can start developing tendonitis in another place. When Phil developed tendonitis in his right arm, he tried to rest it by using his left arm instead. Since he was not accustomed to using his left arm for everything, he developed tendonitis in his left arm as well. It is possible to compensate unconsciously. When Vivian’s shoulder tendonitis first developed, she took anti-inflammatory drugs to the point where she didn’t feel any pain except when she pushed her arm way back. So one day she decided that the woodpile had to be re-stacked, and proceeded to do so, without feeling any pain. The next day her biceps tendon ached badly. Since her shoulder was weakened and out of balance, her upper arm was compensating and developed its own tendonitis!
Braces. Most drug stores carry various types of braces which give support to wrists, elbows and knees. They can be useful in enabling you to use the joint without aggravating the inflammation. A wraparound bandage can do the same thing.
Surgery. Surgery is a treatment of last resort, but in exceptionally severe cases it may be the only way. It is fairly common for carpal tunnel syndrome, which seems to be less responsive to other treatments.
Minimizing stress. The real bottom line in preventing, relieving, or curing tendonitis is to minimize stress in your life. Tendonitis is more likely to plague you and to be more painful and slower to heal when you are under stress and tension. Whatever it takes to help you relax, give it a try, whether it is counseling, diet change, career change, meditation, massages, hot tubs, saunas, avoiding stressful situations, watching TV, or going on a Caribbean cruise.
By Phil & Vivian Williams