Forearm and hand pain
Forearm and hand pain
Forearm and hand pain can be linked to a number of conditions so it is important to get an accurate diagnosis from a medical specialist (see the BAPAM website for a recommended list of practitioners in the UK or to make an appointment at one of their clinics).
It can be rather confusing, as different doctors use different terms. The most commonly used terms nowadays for the kind of non-specific forearm pain that pianists often experience are ‘work-related upper limb disorder’ or ‘non-specific upper limb pain’. As this type of pain is often associated with repetitive movement it was previously known as R.S.I. (repetitive strain injury). It is also linked with forceful movements, hence its other name ‘Overuse – or misuse – syndrome’. As the pain is often caused by inflamed tendons, the term tendonitis (also called tendinitis or tendinopathy) may be used.
There are many possible reasons for forearm and hand pain, so it is important to get an accurate diagnosis from a medical specialist. One possible cause of your pain is inflammation of the tendons. Tendonitis can be very debilitating for a pianist. Symptoms vary, but may include:
Pain or tenderness
Tingling or numbness
Pain may be localised, or may spread throughout the arm. It may come suddenly in response to movement or it may be continuous. There are many forms of tendonitis, just as there are many tendons in the shoulder, arm and hand.
Tendons are fibrous tissue which attach bones to muscles. The bones of the fingers and thumb are attached by tendons to strong muscles situated in the forearm. Tendons are not very elastic or stretchy – it is the muscles which lengthen and shorten to move the bones. Tendon problems often arise when the tendons rub repeatedly against bones or ligaments. As piano playing involves repetition at speed, often at force and over long periods of time, tendons may become stressed beyond their natural limit. Any technical imbalance, such as a very high or low wrist, is likely to increase friction on the tendon as it passes over the joint. Over time the tendon may become inflamed and tender or painful. As tendons have rather a poor blood supply, they may take quite a long time to heal.
Forearm pain and tendon-related problems can be caused by a variety of tasks. They are particularly associated with doing forceful or repetitive activities at speed over a long period of time. Poor posture can also cause muscular imbalance, which can cause some muscles and tendons to overwork while others are weak. Forearm tension (co-contraction) and overly forceful movements may over time lead to pain. As piano playing involves repetitive activity, often at speed and with force, professional pianists in particular are at risk of experiencing some arm or hand pain at some point in their career.
It is important to reflect on what may have caused the pain, so as to be better able to prevent future recurrences. Here is a summary of some of the things to consider:
Were you practising excessively, with insufficient breaks?
Were you playing challenging pieces from cold?
Can you notice any muscular imbalances eg high or low wrist, high shoulders, elbows pulled in or out?
Do you hold excessive tension in your shoulders, arms, elbows, wrist or hand?
Do you play with high, curved fingers?
Do you push into the keys with force rather than releasing into the keys using gravity?
Does your hand and wrist tense up when you open the hand towards a wide stretch?
Do you hold non-playing fingers tense?
Are there are other activities which may have contributed: gardening, heavy lifting, texting, typing?
If you are in acute pain, you may be advised to rest completely initially, to allow some time for any inflammation to settle and for the tissue to heal. A splint or support bandage may be recommended initially to avoid excessive movement and help the tendons rest. Ice may be advised for inflammation, and perhaps some anti-inflammatory tablets or creams.
See Recovering from injury for further advice on rest, ice and elevation.
My experience is that once pianists release the tension in the elbow, the whole arm starts to coordinate with ease, the sound improves and the pain starts to dissipate.
It may also be beneficial to reassess your overall sitting posture (See Sitting Posture in the Online Academy and the Yoga for Musicians DVD), checking that you have a well-balanced torso, with the elbow hanging passively. Some help from an Alexander technique teacher might be helpful.
When a hand or arm has been injured, the muscles tend to lose some of their elasticity. My ‘passive stretching exercises’ can be especially beneficial as they help to regain elasticity and full range of movement whilst keeping the elbow completely relaxed. The exercises show how to dissociate movement in the hands and fingers from tension in the elbow, which will become particularly important when you start to resume playing.
'Namaste sequence’: Place your hands in ‘prayer position’ in front of your chest. Then invert the hands so that the fingers point downwards and the backs of the hands touch each other. Alternate between the two in a flowing motion, keeping the wrist and elbow soft.
‘Floppy arm': Place your hand in playing position on a flat surface. Lower the wrist and elbow very gently, then raise them. Repeat the movement, keeping the arm very floppy and check for any tension in the wrist or forearm. Do each stretch in time with your breathing – always breathing out as you lower the arm.
‘Elastic elbow’: Place your hands lightly on the closed fallboard of the piano. ‘Dust the wood’ by sliding your hands very lightly along the wood towards the extremes of the keyboard, then forward and back and in circular motion. Open up the elbow joint to allow the arm to straighten and move freely.
‘Freely moving hand and fingers’: Rest your arm on the arm of an armchair. Let the elbow and forearm relax fully. Move the hand in all directions, up/down, side-to-side and in circles, as far as possible without tensing the elbow. Then move each finger and thumb in all directions without tension.
‘Opening the hand like a fan’: Rest your arm on the arm of an armchair. Open out the hand extremely gently from the base of the palm (as if reaching towards an octave) whilst keeping the whole arm relaxed.
Do each movement in time with your breath – always breathing out into the stretch.
Roskell piano exercises for tennis elbow
When the pain has subsided and you start to resume some playing, it is very important to build up practice time very gradually and to stop as soon as you experience pain. (See Recovering from injury). Use this time to explore a new approach to technique.
There is no point in going straight back into old habits which may have contributed to the problem in the first place!
The Complete Pianist
The following sections from The Complete Pianist teach very gentle healthy movements which can be beneficial to all pianists during recovery:
The Roskell warm-ups and shoulder releasing exercises
The chapters on the wrist, shoulder, thumb, and elbow may have particular relevance depending on the type of injury
Bringing the hands to the keyboard; improves alignment
The pianist’s hand and finger: minimizing the stretch
The Parachute touch: co-ordinate the arm and softens the impact on the keys by using arm weight
The released hand and finger: reduces tension in hand and fingers
Moving freely around the keyboard: frees up lateral movement and softens the elbow
Rotation technique: releases tension generally
Practising: encourages healthier practice methods
Preparing a piece: reduces practice time by more effective learning methods
Before regaining a full playing schedule it is also important to explore how to play forte without clenching the elbow. The chapters on The Parachute touch in chord playing and Full arm release in The Complete Pianist show how to engage the upper arm in the sound production whilst keeping the elbow soft.
Observe how you use your elbows in your everyday life. Do you hold your elbows tense when typing, texting, playing sport or carrying shopping? Look for other ways to do these activities without clenching the elbow. A physiotherapist, occupational therapist or experienced teacher may be able to help you learn how to avoid tensing the elbow in your other activities.