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Caeli Smith

Musical Injuries: The Halloween Edition

October 26, 2007 at 5:43 PM

Musical Injuries: The HALLOWEEN Edition
"Lesson # 1: if you see a doctor for an injury, and they rely on x-rays and MRI's, but don’t touch you or watch you play, find another doctor." – Christoph Sassmannshaus

Like most musicians, I have a horror story. (Cue scary Halloween organ music.)

I was thirteen years old and in the midst of a practice frenzy, just a few days before leaving for my first summer at ENCORE School for Strings. Late one night, while obsessively practicing a particularly high passage with my left wrist bent at a ninety-degree angle, I felt an eerie, unfamiliar pain in my wrist. The pain didn't go away—until I put down the violin and stopped playing. When I picked up my violin, the pain started up again as soon as I got into a high position. Anxiety shot through my body. Could this be the moment I had always feared?

The next day at my lesson my teacher seemed alarmed and said I should call a doctor right away. If I had developed a dreaded case of tendonitis, I might be forced to rest my hand until it healed, and then my summer of studying with Linda Cerone would be ruined.

My mom made an emergency appointment with Dr. Bong S. Lee, a hand specialist who treats scores of musicians in our area, including many members of the Philadelphia Orchestra. I met Dr. Lee in his office on Rittenhouse Square, a few blocks from the renown Curtis Institute. In his waiting room I was surprised to see my quartet coach, who was there for treatment of her own recurring tendonitis. Over the next several years (as I would be fated to visit Dr. Lee several times) I would run into more coaches, teachers, and fellow music students at almost every visit.

Dr. Lee examined my wrist carefully, poking and prodding, and diagnosed me at once. "You have a ganglion cyst," he said. "It's a small cyst, but the small ones are often the most painful." Dr. Lee explained that these cysts were common among teenaged string players, and that his own son, who had been an elite tennis player in high school, had suffered from one, too. He injected my cyst with cortisone, gave me a splint and told me not to practice for a day or two. Within a few hours, my pain had disappeared; within a day my wrist felt good as new. It was like a miracle. I didn't have tendonitis after all—or did I?

Me and Dr. Bong S. Lee in his Rittenhouse Square office.

As a teenage violinist, I am acutely aware of the need to perfect my technique now, while my muscles and synapses are still young and flexible. Of course, the pressure to practice as much as possible can easily lead to over-practicing and, inevitably, an injury which can set a player back or even create irreversible damage. I've seen it happen to my friends, many of whom have been sidelined by tendonitis and other injuries.

According to Dr. Alice Brandfonbrener, M.D. of Northwestern University, a world-famous authority on performing artists' injuries and rehabilitation, teens aren't the only ones who need to worry about overuse injuries.

"The risk factors are pretty similar for both the young and the old," she told me in a telephone interview. "The only problem that occurs in older adults but not younger people is arthritis. Otherwise, the risk is the same whether you are 18, or 28 or 68. There is no risk or protection from being young, except that very young kids tend not to play as long or with as much tension. That's why it's so important to start with good teaching."

Aside from the obvious issues of posture and position, Dr. Brandfonbrener advocates that musicians learn to practice efficiently and to play without excessive tension. "The more you play and how you play are the risk factors for injuries. I tend to see problems musicians who are preparing for recitals or solos, or who have a sudden increase in rehearsal hours—when there is a crunch in playing."

Crunching for upcoming performances is a common habit among musicians! That’s what happened to 18-year-old Heather Engebretson, a violinist from Alabama, now a voice major at the Cleveland Institute of Music. "I was fourteen, and as a consequence of some stupidity about practicing, I got tendonitis in my left arm and carpel tunnel in my right wrist. I would feel shooting pain and throbbing in my left arm and hand, and a loss of feeling and mobility in my right." Heather saw several doctors and was diagnosed with nerve damage in her left arm. But, at the time, she was preoccupied with preparing for her first solo performance on the national radio show From The Top.

"In anticipation of the show, I kept on practicing the way I always had: an hour and a ten minute break for five hours, a half hour break for lunch, and then two hours in the afternoon. After the show I stopped playing almost immediately." Heather spent two months away from her violin, did regular physical therapy, took anti-inflammatory drugs, and tried acupuncture. A diminutive young woman, barely five feet tall, Heather also found a smaller, three-quarter size instrument. But for Heather, the damage was done. "I'm not, nor will I ever be, completely fine again as far as my arms are concerned," says Heather, who continues to play her violin as much as her arms permit her, but now focuses her musical energies on her budding opera career.

According to Dr. Brandfonbrener, many musicians diagnose themselves or receive a diagnosis of "tendonitis" which is not correct in the clinical sense. "I don't always use the term 'injury' which, strictly speaking, implies a disruption of tissue. Musicians often have pain that is generated from playing, but what they are experiencing may not be "injury" in a technical sense. We call these "muscle-tendon pain syndromes" because the pain is in the muscles and the tendons that are attached to the muscles and joints. Sometimes it is "for real" tendinitis, but sometimes the medical term tendinitis isn't justified for degree of inflammation that we see." But, this is an academic distinction, according to Dr. Brandfonbrener, because, as we musicians know, the pain is very real.

Real pain can be real hard to diagnose. My 18-year-old sister, Madeline, a violist, suffers from severe upper back pain, which is extremely common among violists according to Dr. Brandfonbrener, whose violist daughter Amy is a graduate of Curtis and New England Conservatory. "Violas are heavier, larger, and more awkward to handle [than violins]. Upper back pain can have to do with posture issues, or their set-up for playing. We want to look for the optimal set-up—yet, for violists, there is no perfect set up. Sometimes, the muscles in upper back that hold the shoulder blade in place are poorly conditioned. I have them consider the size of their viola, and whether they practice standing or sitting. We look at posture, and the size of the shoulder rest and chin rest."

My sister has been through years of physical therapy, Alexander Technique lessons, chiropractor visits, deep massage, and other therapies. She has had multiple MRIs and even a sleep study (which diagnosed disturbances in her sleep caused by chronic pain). She's tried a smaller instrument, an array of shoulder rests, and instruction from various teachers. Next week she is going to begin Rolfing sessions with a practitioner who specializes in musicians. The more she looks for a solution, the more elusive the solution seems. But maybe, if she keeps looking, the answer will be just around the corner…

Take the case of 18-year-old cellist Christoph Sassmannshaus, the son of legendary violin pedagogue Kurt Sassmannshaus of fame. Christoph was fourteen years old, and studying with Richard Aaron at the Aspen Festival in Colorado when "a small, mountain-shaped swelling" formed on his left wrist and he felt sudden snapping and popping sensations all up and down his left arm.

Christoph's parents took him to a doctor in Aspen, who prescribed anti-inflammatory drugs and two weeks' rest. "That turned into a two-year drama," says Christoph. "I tried everything that doctors suggested, without luck. They always seemed positive that this new treatment was really going to work. I tried tendon stripping; acupuncture with and without electro-stimulus; electro-stimulus; applications of heat and cold; strength training; swimming; yoga; Pilates; Alexander technique; Tai chi; and a chiropractor. I had an MRI in March of 2003. Unfortunately, my little mountain did not show up on the MRI." Christoph later determined that in order to get the swelling big enough for the doctor to see it, he had to first play his cello for as long as it took.

"The first hand surgeon I saw said that if the swelling was not on the MRI it didn't exist; therefore I didn't need surgery. I believed the MRI and I believed him; he was the surgeon after all. I started to strength-train my injured arm. But this only made things worse."

In desperation, Christoph's parents took him to the Miller Healthcare Institute for Performing Artists in New York. Right before this appointment, they went to a violin shop in New York where he could practice, in hopes that the swelling would appear and stay through his visit with Dr. Lillie Rosenthal.

"Dr. Rosenthal did something the surgeon in Cincinnati had never done," says Christoph. "She touched my arm. Lesson Number 1: if you see a doctor for an injury, and they rely on x-rays and MRI's, but don’t touch you or watch you play, find another doctor." Like Dr. Lee did for me, Dr. Rosenthal immediately diagnosed a ganglion cyst. "My mom cried on the cab ride through Central Park and back to the airport," says Christoph. "We'd known all along that there was something in there, but we just couldn’t get the hand surgeon to agree."

"Ganglion cysts are a form of tendinitis," Dr. Brandfonbrener explained to me on the phone for more details about the condition that Christoph, I, and countless other musicians share. " These cysts are very common. They are not fatal diseases. They occur where a tendon glides over a bony surface. They tend to start in the joint cavity and grow out like mushroom. The natural tendency for these cysts is to wax and wane. The cysts cause pain because they are space-occupying objects. They crowd things in a place where there is a lot going on in very little space.

"There are a number of ways to deal with them," she continued. "You can ice the area after playing, and avoid flexing any longer than necessary in the higher positions. You can cut down on playing. Ibuprofin sometimes helps. I find that trying to take the fluid—it's really gunk!— out of them does not often result in resolution.

"And, of course," she said, "the last option is surgery." After a year of torment, this was Christoph's option. But it was not without risk. "Any surgery, even if done by best of hand surgeons, is major surgery. Regardless of the surgeon's skill, it could cause bleeding or scar tissue."

When I first met Christoph, he was seventeen, fully recovered, and performing a beautiful, soulful rendition of Ernest Bloch's "Prayer" from Jewish Life on a From The Top taping in his home city of Cincinnati. If I hadn't known that he'd been forced to take an entire year away from his cello studies, I'd never have guessed. So his horror story has a happy ending: soon after his diagnosis, Christoph had his surgery and experienced the best possible results. He came back slowly and carefully, taking a full year to rebuild his endurance, and is now a stronger player than ever. But it's still scary to think that Christoph could have experienced so many frustrating misdiagnoses and dead-ends. If a young musician with the best imaginable resources and connections, and such high motivation for recovery could be waylaid for almost two years, what are the chances for the rest of us in finding relief from performance injuries and pain?

In some ways, it seems that it might be better just to give up music—but something in the spirit of musicians makes us not want to stop playing, even when playing hurts. My sister, who is always in pain when she plays, doesn't want to stop.

"I don't advocate for musicians to stop playing altogether," says Dr. Brandfonbrener. "Most problems are fixable, and for the really serious ones, it doesn't matter if you play or not. I try to get my patients to modify their playing instead of stopping it. For example, it is sometimes necessary to cut down on rehearsals or avoid a certain piece of repertoire. It's better psychologically to change habits than to stop playing."

In my case, I was lucky enough to find a hand specialist with a deep knowledge of music-related injuries, and to find him on my first try. My cyst tends to re-appear during bouts of intense preparation for recitals and competitions, and Dr. Lee's injections have worked quickly effectively…until the cyst comes back. On my most recent visit, he told me that cortisone would no longer be an option, because repeated exposure to the drug can weaken the tendon, which could cause a rupture.

The next step, he told me, would be surgery. But I should not consider this option lightly. He advised me to re-examine my practice habits: to avoid long stretches without breaks. He told me to take care when flexing my wrist to open heavy doors, and to sit out any long rehearsals where I would have to play a lot of endless, continual vibrato. To that end I decided, with some reluctance, to leave my youth orchestra, whose three hour rehearsals often morph into longer marathons with few breaks during rehearsals for concerts.

When I asked Dr. Brandfonbrener about my personal situation, she was encouraging. "You have a very conservative orthopedist, and I agree with him," she said.. "He's right that should not have another cortisone shot—there is a cumulative potential negative effect from these shots, and last thing you want is for your tendon to rupture. Take many breaks while practicing. Put the instrument down every fifteen minutes, even if it is only for a few minutes. Practice smart—do as little as you need to, to get the job done."

I've been a little nervous since Dr. Lee declined to give me another cortisone shot when my wrist started hurting in early September. But careful practicing and keeping conscious of how I bend my arm, and perhaps a little luck, has kept me pain-free over the past couple of months. Maybe my horror story won't have such a horrible ending after all.

Fully recovered, Christoph performs "Julie-O" by Mark Summer of the Turtle Island String Quartet

From Corwin Slack
Posted on October 26, 2007 at 7:54 PM
About 12 years ago I decided that I needed a tenths technique. After practicing them for a few weeks I felt some rather significant pain in my left hand. I put the violin completely away for a few months (a luxury we amateurs have) and when I resumed I didn't go close to tenths.

Sometime later I found my teacher who corrected numerous problems that he ascribed to my reliance on a shoulder rest. Over the years my technique has been completely reshaped.

In the last year I have resumed study of tenths and I can say that I can now play tenths scales and passages (perhaps not as totalyy reliably as I would like) but there has been absolutely no pain.

My question is then when does pain justify a reexamination of our basic premises of violin playing. When do we turn back down the road we have been on and see if we can pick another road?

I am afraid that many young musicians are so intent on a particular path to musical success that they gloss over fundamental problems and avoid backtracking and reworking in order to avoid "falling behind". This kind of doubling down is a bad bet and the payoff is usually zero.

"Start over" is frequently the correct choice.

From Bill Busen
Posted on October 27, 2007 at 4:09 AM
One way of addressing the psychological element of "needing to play/practice" that aggravates injuries is to proactively develop the away-from-the-violin capabilities of visualization and audiation when not injured (or even when injured). As I understand it, it works because vivid visualization of a movement activates the same cortical regions as movement, with an additional Inhibit signal from frontal cortex inhibiting the movement so that nothing actually happens in the brainstem (and beyond).
From Pauline Lerner
Posted on October 27, 2007 at 5:24 AM
Thanks for the detailed medical review. I hope that your sister and everyone else similarly afflicted will get the right treatment and heal. I'm glad that you recovered without spending years working on the problem.
From Corwin Slack
Posted on October 28, 2007 at 2:24 AM
Bill, I think a lot of music that is readily within someone's technical grasp can be practiced successfully away from the violin but the very most difficult passages demand our hands on practice. If there is any flaw in our technique we subject ourselves to injury by repetitively worrying the flaw.
From E. Smith
Posted on October 28, 2007 at 4:57 AM
Corwin, I may be misreading you, but you seem to be suggesting that injuries are due to flaws in technique. That is certainly sometimes the case, but there are other reasons for pain and injury and it does seem unfair and reductive to blame the victim for "gloss[ing] over fundamental problems."
From Corwin Slack
Posted on October 28, 2007 at 6:10 PM
You probably are not misreading me. Unless a violinist has residual damage from a non-violinistic injury that is exacerbated by playing the violin, most "violin" injury comes from some technical defect. or overuse. Correct technique can bear a lot more overuse than incorrect technique. I include posture defects as technical defects.

However, incorrect technique is not a moral or character flaw and it can afflict even the most talented players.

From Corwin Slack
Posted on October 28, 2007 at 6:17 PM
One more thought: when a young person is doing very well and making rapid progress it's easy for the individual, his teachers and his parents to ignore small and festering issues. Then they erupt into large and debilitating problems. The victim in this case is almost always the victimizer aided and abetted by parents and teachers. Technical defects are not moral issues but forcing someone to overlook them and gloss over the real problems can certainly become such.

Read all the literature on the development (and mis-development) of young ballet dancers and just see how much fits the violin world. Then add in gymnasts and skaters.

From Corwin Slack
Posted on October 28, 2007 at 6:29 PM
I ought to concede one point: A lot of people play instruments that they are not suited for. No amount of technique can fully correct a mismatch between player and instrument. Injury is nearly inevitable and questions ought to be raised on why an inappropriate choice of instrument was made or allowed.

I speak particularly of the viola. It is not an instrument for children at all and many adults are unsuited for it.

I also will add that there may be good uses for a shoulder rest but using it to correct a mismatch between body-type and instrument is not one of them.

From Marsha McCoy
Posted on October 28, 2007 at 11:26 PM
Wow! I almost missed this post. What an interesting read. I had no idea that so many things could go wrong. I'm so glad that Dr. S's son recovered and the video you posted of him is just wonderful. I'm glad you included it.

This article is jam packed with great info. I hope you do well with your cyst. Thank you, Caeli.

Love the Halloween pic, too.

From Nico B
Posted on October 29, 2007 at 3:49 AM
What a great article. I have read that musicians have the highest risk of work related injury of any professions so it's really helpful to have an in depth story like this one. It is encouraging to hear how people are able to work around their injuries or come back after layoffs. Your article gives the perfect view of what many musicians have to cope with.
From Bilbo Prattle
Posted on October 29, 2007 at 12:21 PM
Caeli, this is an excellent article. It brought back a memory that I had forgotten: I had a ganglion in my left writs as a teenager, but not from violin per se. It flared up during hockey season, in one year when I was playing a lot of squash, too. My orthopedic surgeon at the time recognized the ganglion behavior right away. It never amounted to a totally debilitating problem; I kept playing hockey and squash, though I lay off the latter in intensity and most importantly in my case, I avoided large extensor loading with the wrist flexed. It eventually stopped bothering me.
From Sharon Mehlman
Posted on October 30, 2007 at 3:56 PM
Caeli, thanks for this very interesting and informative article. I hope your wrist heals soon.

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