Golfer's Elbow

July 11, 2014 at 07:07 PM · Hi Everyone,

I was in my first year of grad school for violin performance this past spring when a particularly intense performance caused my pinky and ring fingers on my right side to go numb and considerable pain in my right elbow. I have always had some slight irritation in my elbow after long rehearsals or practice sessions, but it has always gone away after a few hours. I figured some ice, ibuprofen, and rest would do it, but 3 months of not playing and it is just as bad if not worse. Doctors have diagnosed me with golfer's elbow and they have basically said there is nothing else I can do but rest. I have tried KT Tape, acupuncture, massage, physical therapy, sugarless anti-inflammatory diets, and even a cortisone shot. Nothing has helped. Now I'm even getting a slight snapping in my elbow when I extend it and my fingers are tingling pretty much all the time. I'm really frustrated that doctors have dismissed it so quickly and I haven't found anyone willing to try different solutions.

I'm wondering if any of you have had a similar issues in your bow arm. I'm really worried that I will not be able to finish my final year of grad school, so I am open to any suggestions!

Replies (22)

July 11, 2014 at 09:05 PM · Kaitlin,

Impossible to tell what is the root cause, without observing you play. This is what helped me.

1. Setup: if you are using shoulder rest, make sure it is not too high. If it is, lower it, or replace with a pad. The point is to reduce unnecessary elevation of your whole right arm and elbow

2. Warm-up/preventative exercise: http://www.youtube.com/watch?v=LtR8fYEUnXI

Talk to your physiotherapist and, if approved, start with Yellow bar (the least stiff). Do not start exercises if in acute pain; wait until inflammation is over.

3. The way you hold the bow and draw it across the strings. This could also be caused by "broken wing" movements (often seen when a player has got long arms), when your wrist is too high and bent, while elbow dropped.

Good luck!

July 12, 2014 at 12:47 AM · Thank you both! I haven't really thought about making my setup lower, I'm going to look into that. I think I do probably play with the "broken wing"

Here is an example:

http://vimeo.com/m/84090687

July 12, 2014 at 01:47 AM · Had something very similar 15 years ago, cortisone shot and therapy did not help. Our dog's vet cured me when he saw me gingerly holding our Golden's leash. He gave me some DMSO to put on the elbow with a Q-Tip. Wash the skin first. Medical grade DMSO is a lot better than the crap DMSO from GNC. Bark like a dog or meow and get some from your Vet.

July 12, 2014 at 02:00 AM · Kaitlin, can't get your link to work. Sorry, could be my puter, too.

July 12, 2014 at 02:17 AM · Thanks Ray! I have never heard of that, what exactly does it do?

Here is another video, from a while ago but you get the idea.

http://youtu.be/hpI_VOpZHdM

July 12, 2014 at 03:07 AM · very nice playing! I'm not expert in this at all, but it seems your bow arm is doing some odd kinking when you play the G and D strings. It looks good on the E and A. They should be about the same but higher level, and they're not. Can you find someone who's really good setup and on playing injury free? Tendonitis like this comes from having a slightly bad position that puts a little stress on it, then repeating it a zillion times. Nothing will help if you don't get the stressful motion identified and eliminate it. I'd stay away from cortisone shots and all that if at all possible- they give short term relief, but always seem to contribute to longer term problems. Give it a lot of time to heal as tendons don't have an independent blood supply and can take several months- but healing only starts after you eliminate the motion causing the stress. You can still do visualization and mental rehearsals. Good luck with it!

July 12, 2014 at 04:22 AM · Thank you Tom! I'm not sure what you mean by kinking, could you explain more? I agree with you about the healing, I need to find someone who can really help me figure out what habit caused this. When I'm playing there isn't any particular motion that gives me pain so it's hard to pinpoint. I know golfer's elbow is caused by pronation...

July 12, 2014 at 03:08 PM · The elbow and knee joints are hinge joints, and the only time they work freely is when bones they connect are roughly in the same plane. They don't accommodate any twisting action, as the shoulders and thighs do. These golfers and tennis elbows don't come from the sports, per se, but from players who add some rotation to the elbow joint. Same with runner's knee- a foot problem, worn shoe or something can add some rotational component to the knee, and out it goes after enough repetition. So that's what I mean by a kink in the motion- something other than pure opening and closing in the same basic plane.

Watch this video of Hilary Hahn- it has a very good camera angle to show this- she keeps the upper arm and lower arm (with bow) in the same basic plane on all strings, with just a nice, straight opening and closing of the elbow, i.e. no rotation of the forearm.

http://www.youtube.com/watch?v=x7xPIyePmNk

Maybe you could try thinking of your whole right arm as an assembly, and try moving the position of the assembly from the E string up to the G string without changing anything, and see how that feels. Probably have to concentrate to keep the hand and wrist in the same position as well. If you've been rotating the forearm, it may feel different if you consciously don't rotate it.

July 12, 2014 at 03:20 PM · Sorry for the silly question but are you a golfer?

July 12, 2014 at 08:48 PM · Smiley, Smiley, Smiley.

I once suffered for a long time from "Golfer's Elbow": "medial epicondylitis" as opposed to "lateral epicondylitis" which is called tennis elbow".

Mine, left elbow, came from tatting which requires the hand to spread and partially close hundreds of time a session.

July 13, 2014 at 12:08 AM · Patrick, do you play golf also?

July 13, 2014 at 01:51 AM · Smiley, beyond swimming years ago, yoga and water aerobics I do not generally participate in sports. And I haven't made lace in several years (tatting and bobbin lace).

My brother golfed back in the early 70s and I went out with him once. On the Chemcel Club Grounds between Kingsville and Bishop Texas you did not golf without having to kill one or two Cottonmouths (Agkistrodon piscivorus)each round, a nine iron works well. So I did not get into it very much. Never ate one, I hear they're fatty like a mud cat(Pylodictis olivaris). Rattler's not bad and I do have a rattle in one of my fiddles (Crotalus atrox). But no I do not golf.

Remember golf backwards spells FLOG.

July 13, 2014 at 11:19 AM · Hi Kaitlin, sorry to hear about your injury. You might want to carefully observe your right wrist in the video a) to the tendon which sticks out on the pinky side of your wrist and b) to the coordination between your forearm and your hand. It might be a combination of factors, but given that Golfer's elbow is an inflammation of the inner side (epicondyle) of the elbow, and that the flexor carpi radialis originates on the medial epicondyle and attaches to the base of the hand and serves to flex the wrist and also bend the wrist sideways (radially abduct, bend to the pinky side,) you might be overusing the flexors by flexing while bowing in general, but in particular on bow changes at the frog. Also the pinky might be pressing beyond balancing the bow, stressing the flexor carpi ulnaris, the flexor on the pinky side.

A few things you might try:

1) align your wrist so it doesn't bend sideways. It helps to supinate the forearm as you approach the frog (rotate the forearm as if you're turning a doorknob clockwise.)

2) help counterbalance the weight of the bow at the frog with the 3rd finger, don't let the pinky do all the work. It also helps to twist with the thumb and middle finger in coordination with the 3rd and 4th fingers clockwise, as you approach the frog. Check that you're not pressing the stick with both the 1st finger and pinky simultaneously, but rather, make sure they work together to pivot the bow, like a see-saw with the thumb as the fulcrum.

3) coordinate your bow change so the wrist extends (opens) as you pull down bow from the arm. Right now it looks like your wrist flexes as your arm moves down bow.

But here's the interesting thing. None of the above may be the real problem at all. According to some, the mainstream medical establishment has yet to catch up to the latest research in pain. Research shows there is no direct, causal connection between damaged/injured tissue and pain. As it turns out there are plenty of people walking around with degenerating discs, or bursitis, or tendon tears, etc., who present with no pain. And plenty with no physical damage (or long healed physical injuries) who continue to experience pain. The brain acts as an amplifier of signals from nociceptors, the pain receptors, to protect the body (or whole organism) from potential danger, whether injury or death. In other words our experience of pain is a signal from the brain rather than a direct signal from the body.

The mystery behind chronic pain may have more to do with the way the brain interprets signals it receives from the periphery. For instance, you're walking in the woods but forgot to bring your hiking boots, and instead you're forced to keep up with your intrepid guide only in flip-flops. Just the fear of jamming your toe, or cutting your foot on rocks can make your brain interpret the slightest sensation in your feet as injury, which you will experience as pain, until you take a look and see that a twig merely grazed your skin. On the other hand, you sprain your ankle but are being chased by a bear. You don't even notice the injury until you're back in your car driving away from danger. The brain downgrades the signal from the nociceptors in your ankle until your life is no longer in danger, until you're safe to do something about that ankle.

In our case as musicians, we might haved pushed too hard to cram for a jury, working through fatigue (there might even be actual tissue damage at one point) and while in 'survival mode' you don't feel a thing. But after the danger (of trial by that ever-so-threatening panel of professors) your brain knows it's now time to slow down and even if there's no actual injury, it starts to make things hurt so you will do just that. You fear the pain means something serious, but you know you have to get through your graduating recital so you keep practicing. But without the immediate fight/flight conditions of an actual performance, your brain prioritizes rest over the need to survive a recital a month down the road. Your brain only knows to protect you from immediate danger, and so ramps up pain signals. You now start wondering if there's something going terribly wrong, if this could be a career ending injury. Your doubt convinces your brain there's immediate danger when you make such and such a movement; your brain sends even more pain to prevent said motion.

Now to a medical materialist, pain can mean only one thing: tissue damage. There are only two answers: mask the pain, or 'repair' the damage. The problem is that pain, the brain... we are much more complex than mere matter can tell. A better strategy to deal with chronic pain might be to coax the brain into believing things are actually ok, that the motion is safe.

Check out the links in these threads:

http://www.violinist.com/blog/Xixi/20128/13884/

http://www.violinist.com/discussion/response.cfm?ID=23059

Try mobilizing your arm and do self massage (trigger point) on the flexor muscles.

Hope you recover soon!

P.S. You might also look into gluten related inflammation.

P.P.S. There are trigger points in the shoulder complex which can radiate down the arm and hand. Check out your infraspinatus and the difficult to treat subscapularis.

P.P.P.S. I knew a violinist who was diagnosed with carpal tunnel (and actually had unsuccessful, incapacitating surgery) when the real problem was at the base of the cervical spine (neck.)

~~~

Tom, the elbow actually has two joints which attach to the two bones of the forearm. The thumb side bone rotates around the pinky side. So the pinky side (or ulna) forms a hinge joint, but the thumb side (or radius) forms a limited ball and socket joint with the humerus (upper arm bone.) I would counter by suggesting that ignoring the rotation of the forearm (in this case by supinating) can add to the stress at the wrist when bowing near the frog with a low elbow. And if golfer's elbow is caused by excessive pronation the solution might be in releasing it by supination.

July 14, 2014 at 05:10 AM · Speaking of pronation Kaitlin, you might also check what's happening as you approach the tip. It's just speculation but an image of your right arm stuck in my head and I wonder if your arm is working at cross purposes with itself. Though your elbow appears low relative to the wrist, it actually remains quite high relative to the angle of the bow, so that the line from elbow to shoulder is above parallel relative to the bow in general. That suggests to me you use quite a bit of torque through inernal rotation at the shoulder and pronation in the forearm to generate tone, while excluding the weight of your upper arm. You might experiment with releasing the deltoids (shoulder muscles which raise the arm) and bowing with a more neutral rotation and pronation (try using a cello grip to unwind) using more weight and less torque, especially for the upper half. Think of pulling through the wrist down bow to the tip, rather than 'pushing' from above. Exaggerate a low elbow and flatter wrist and keep the plane of the arm parallel to the bow to get used to it. Many violinists have their elbow lower than their hand at the tip, especially on the G string. If you need more room to keep the wrist extended at the frog try swinging the fiddle more to the left. This might require overhauling your setup, but might be worth the effort. Off the top of my head, study Shmuel Ashkenazi, Oscar Shumsky, Hilary Hahn, William Preucil.

July 14, 2014 at 11:13 AM · It's possible they could have missed a ganglion - I had one on my left wrist - but unlikely as in my case a shot of cortisol dealt with it.

I also had tennis elbow in my right arm - not from violin or viola playing or tennis (My "backhand" was never even good enough to provoke it) - which is when the pain is on the outside of the elbow; I'm not sure that it's gone entirely. I don't need to tell you golf elbow is when it's on the inside of the elbow. But when the pain is all round the elbow (apologies for this!), it's got to be polo elbow.

Ray, a Search for DMSO on GNC's website yields negative results, so I think GNC must have realized the faecal quality of their product.

July 14, 2014 at 11:59 PM · Here's a few ideas to look in to:

- The further the index finger is from the middle finger the tighter the hand becomes. When we extend the index finger too much up the bow this will make 1/8 and 1/16 notes more of a wrist and elbow movement(unhealthy), instead of a finger movement with some wrist and elbow movement(healthy). I find a 1/4 inch gap is all that is needed; a larger gap doesn't equal better IMO.

- Bow 'over' tilted constantly or pinky is on the shelf instead of the top's edge. I consider playing with pinky on the shelf a weak technique. It also weakens or interferes with bouncing bow techniques.

- Having a high elbow when playing on the E string; this is going to cause some tension you need to fix this habit.

- I find it healthy to have the pinky on the bow with a down stroke, but the pinky should come off the bow for the up stroke.

- Holding the violin at a 45°-60° is better(healthier) for the right arm.

- You need to look at getting a real chin rest also. Keep it mind the chin rest will determine which angle you hold the violin at. Your current chinrest or set-up is causing you to hunch forward a bit. This posture problem is going to restrict your breathing, and when our breathing is restricted our body has problems getting oxygen to our tendons and muscles. Learn to breathe with your diaphragm, and practice this while playing.

- Get a new bow re-hair or alcohol bath every 3-6 months. When the rosin gets old on the hairs we loose grip and this will cause tension in the bow arm.

- Anything that is done to increase blood flow to the area is good, anything done to restrict blood flow is going to cause flare ups.

-Foods that increase blood flow: strawberries, beets, avocado, nuts and seeds,(hazel nuts - high in vitamin E, sunflower seeds are high in B vitamins), fish oils.

- Foods the slow blood flow: alcohol, salt, simple cards, high carb diet.

- Try to exercise 2-3 times a day for 5-10 min. e.g. brisk walk, jog, yoga. Any light exercise to get the heart pumping.

Not saying anything said here will cure this problem, but it is up to you to analyze your technique to find out what you are doing wrong that is causing flare ups.

July 15, 2014 at 01:32 PM · Jeewon, we may be able to play through some pain, but we should never play through injury. And I agree with you to a point, for example fibromyalgia seems to be a problem with mind causing pain than the muscles. Pain can also be a memory and the more we think about the stronger it becomes.

July 15, 2014 at 04:29 PM · Well, lots of advice.

I do think that your arm and wrist in particular do move about too much. Remember that too much wrist movement can have a negative effect on tone production and can lead to loss of contact during the bow stroke. You play well but more contact into the string would be good.

If you look at Milstein (the greatest example of good use) in some youtube videos you will see a minimum of movement, no matter how complex and difficult the music.

July 17, 2014 at 05:07 AM · Hi Charles, I guess it's a question of how one defines an injury. I think we all agree, to ignore an acute injury (trauma, breaks, sprains, tears, bruising, swelling, where there's clear tissue damage) would be foolish, and probably almost impossible to play through. For acute injury, traditional Western medicine's got us covered, depending on how good your insurance is S. of the 49th, I suppose.

But for recurring pain, long after any trauma, or pain which pops up with no clear trauma, for chronic pain (or Phantom Limb Syndrome an example for which 'convincing the brain' is a most effective, and possibly the only, treatment) the research doesn't seem to back the status quo. It's not me you'd be agreeing with "to a point," it's the research. The notions of over-use, repetitive strain, muscle imbalance, micro-tears, tightness, structural problems, etc. can't explain chronic pain. Google "lower back pain and job dissatisfaction." Read Your Back Is Not "Out" and Your Leg Length is Fine.

Even still, I agree with you to a point but...

On the way to work I once sprained my wrist swerving and stopping my bike when a pedestrian suddenly stepped off the curb and in front of me. The show had to go on. It hurt like the dickens but I could still play so, fool that I am, I did, as no subs could be called in time. There are such situations where I think musicians feel they don't have a lot of choice but to play through injury. I hope things are changing, but often freelancers (and possibly many students, even tenured symphony musicians) feel pressure to keep playing. So what then? In Paul Ingraham's opinion, "[y]ou simply have to find an individual professional who cares, someone who is a determined, humble and open-minded troubleshooter, someone [sic] isn’t obsessed with structuralism. It’s a tall order!" And do whatever self-treatment you can find that works. I probably should have found such a professional. It took over a year for my wrist to be pain free, but in the end, when I discovered it, I convinced my brain to get over the pain by mobilizing.

For my left shoulder, a 'playing injury,' I had to completely overhaul my setup and, while not perfect, mobilizing helps keep it limber (and if you believe the research, improved pain, greater mobility is a direct result of restoring and maintaining the brain map for the shoulder's full range of motion.) Either way, whether for acute or chronic injury, movement seems to have become an important part of recovery (if you dig for more info; the idea of complete rest seems to be old school.) But in the case of chronic pain it might be key.

The main point in my previous post is that pain does not equal injury; even in cases of trauma, the brain modulates pain to prioritize your action. Just the fear that pain must represent injury makes it worse. In the case of chronic pain, ceasing all movement in the 'injured' part might actually be counterproductive. Ceasing painful movement is probably a good idea, but mobilizing has worked to improve, and eliminate pain for me and a few others I know.

July 17, 2014 at 05:06 PM · Ok. I may be opening myself to a bunch of incredulity, but I had golfer's elbow for a very long time. I didn't want to stop playing golf and my work had to continue, so I just suffered along with it. My wife insisted that I try one of these. She is much more "open" in her beliefs than I am so I went ahead with an order to please her. Something worked, it might just be time, at least that would be the easiest explanation to digest, but these look great, I like the handmade quality and the craftsman, and wearing it coincided with the end of golfer"s and tennis elbow. I've been wearing it for seven years with no recurrence and plenty of golf. Give one a try. Just remember to take it off when playing so as not to ding the top of your instrument.

http://www.thewonderbracelet.com/

August 31, 2014 at 12:05 AM · Reading quickly through the replies I did not see any mention of doing some light weight training. I am new to violin (at age 70) and practice 2 or more hours each day, but am not having any physical discomfort. This may be because I have a regular physical workout regimen. I swim laps 3-4 times a week and also do some light weight training at home 3-4 times a week. I use 15 lb. dumb bells but you might try 2 or 5 lb. to start. I suggest joining a gym where you can get some help if this would fit with your life style.

August 31, 2014 at 11:43 AM · Might I (very humbly) suggest a temporary but complete change in bow-hold:

- try holding the bow as for a bicycle handlebar, obtaining tonal graduation with the the arm only;

- try a higher or lower elbow than usual, to awaken and use different muscles.

Then, remember to release tension between phrases, almost to the point of dropping the bow: concentration and willpower are great inducers ofparasitical tension.

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