Jun 1, 2016

It’s hard to understate just how valuable hands are to a professional musician. One of the favorite pieces of gossip in classical circles is speculating for what princely, million-dollar sum superstar pianists or violinists insure their hands. They are their tools and livelihood, but they also are subject to immense chronic strain over a career.

Surgeon and physician Raymond Wittstadt thinks a lot about musicians’ hands. Wittstadt is a partner at Greater Chesapeake Hand Specialists and the director of the Performing Arts Medicine Clinic at Medstar Union Memorial Hospital. Wittstadt specializes in working with musicians — including many from the Baltimore Symphony Orchestra — and he describes them as “small muscle athletes.”

Where traditional athletes work larger muscle groups and suffer isolated, single-point injuries, musicians’ injuries — which often fall into the category of what is called performance-related musculoskeletal complaints or PRMCs — are usually the result of extended wear and tear from the accumulation of countless muscle movements over years of performance.

“It’s probably the worst things to do with your hands,” Wittstadt said. “I can’t think of anything else that's close when you think of the time and effort that goes into acquiring these skills.”

To give a sense of scale, Wittstadt explained that a pianist playing the presto movement of Mendelssohn’s First Piano Concert will make more than 5,000 finger motions in just over four minutes. A percussionist playing a snare drum for 14 minutes will contract muscles in the arms 5,144 times.

“Try tapping your finger on the table 5,000 times in the next four minutes,” he said. “Now if you’re a musician, not only are you doing that but you are required to make those movements with absolute precision.”

Compared to the field of sports medicine, performing arts medicine is a young field and there have only been limited studies into how chronic pain associated with playing an instrument develops or just how wide spread an issue it is. But the studies that have been conducted show it is far from an isolated issue.

A 2012 survey in Australia of full-time professional symphonic and pit orchestras found that 84% had experienced pain and injuries associated with playing rehearsals and concerts. Of those, 28% had taken time off in the past 18 months because of this pain, and many more thought it had affected their performance. Musculoskeletal injuries can manifest early for musicians. Wittstadt cited a 2009 survey of music conservatory students — who are at an age group that is on average much healthier than the general population — where 79% said they had suffered from pain related to performing.

“It’s only in the past 30 to 40 years that we’ve started to do these studies on musicians,” Wittstadt said. “What makes it difficult with musicians is that [most of their injuries] aren’t simple cause and effect. If they come in and say their hand hurts, most likely it’s not a hand problem. The hand issue is most likely a result of them overcompensating in another area.”

One source of that overcompensation is that many musical instruments require a musician to use their muscles asymmetrically. Playing a violin uses the arm, shoulder and back muscles to different degrees on the right side and left side of the body. Brass players who hold their instrument up in front of them might have tighter muscles in front with looser muscles in their back.

“Because musicians do start playing very young, their bodies and muscles often develop to accommodate that instrument,” Wittstadt said. “It’s not uncommon for me to be able to tell what instrument someone plays when they take their shirt off [based on their muscle development.]”

The natural instinct is to allow those dominant sides to overcompensate rather than trying to work up the less used muscle groups away from the practice room. Wittstadt said many musicians are guilty of taking better care of their instrument than themselves, and he often advises them to approach their personal fitness with same dedication they do their musical craft — because the two are connected.

Thinking about musicians as athletes, Wittstadt said, is an emerging concept, and performing arts medicine is trying to merge with sports medicine to apply research and techniques to better treat musicians.

“Like athletes, musicians perform for the public and can lose their job if they don't perform,” he said.

Because of the highly competitive market for musicians, missing too much time to rehab an injury is a terrifying prospect. The last thing a musician wants to be told by a doctor when they explain that it hurts when they do something is “Well, then don’t do that.”

To treat musicians properly, Wittstadt said it is necessary to understand their musical history and environment just as much as knowing their medical history. New repertoire, increased practice load or technique can all be factors.

“Until I see someone play, [it’s hard to diagnose them],” Wittstadt said.

While technique on any instrument has been refined and passed on over generations, it’s not entirely standardized — and what has been standardized has been done so with performance in mind, not long-term health. Some musicians might be playing with excessive force or tension in their body, which can contribute to pain.

Similarly, sometimes practice routines have to be rethought. Musicians working on a difficult passage often want to repeat that section over and over before moving on to feel like they’ve mastered it. But this also uses the exact same muscle contractions repeatedly, and if the section is physically strenuous, Wittstadt said it would be better to schedule in breaks to work on other parts that are less intense or work different muscle groups.