Seeking medical advice for treating tendinosis.

January 17, 2015 at 10:29 PM · Long time lurker here. I'm not a doctor but I have suffered my share of debilitating repetitive stress injuries. What I learned is that pain and injury in one area of the body can often be referred from an imbalance in another part of the body. For example, spending hours typing with rounded shoulders can cause carpal tunnel syndrome in the wrists. In this case, the wrist pain is merely a symptom of a muscle imbalance farther up in the shoulders, which is caused by imbalance between the chest and back muscles that hold the shoulders in place.

Walking with a pronated, toed-out foot will cause wear and tear on the knee joint with every stride. If the painful knee joint gets replaced but the foot stride isn't straightened out, the torquing can travel up to the hip causing hip problems later down the road.

I learned about muscle imbalances and the role they play in R.S. injuries from a brilliant little book called "The Egoscue Method of Health Through Motion," written by a physical therapist named Pete Egoscue. It explains how the musculoskeletal system is interconnected, and provides a custom-tailored approach to correcting muscle imbalances. The exercises are simple isometrics that train the body to "wake up" and use all its muscles, instead of overusing some muscle groups while underusing their opposite pairs. When this happens, posture is corrected, repetitive stress injuries can heal and their pain goes away.

This book helped me tremendously. Maybe it could help you, too.

January 17, 2015 at 11:07 PM · Hi Matthew, I would've thought the obvious thing to do would be to consult a physical therapist. The following is not medical advice, but if you want to explore non-invasive options you might be interested in these threads:

http://www.violinist.com/discussion/response.cfm?ID=25868

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

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

If there's no trauma to the area, and if you can afford it, complete rest is probably the easiest and most effective thing you could do. If you're doing something which causes the pain, then reversing that action is the next step when you resume.

If it is the extensor carpi ulnaris I would guess you bend at your wrist sideways as you play (wrist adduction, or ulnar flexion/deviation.) You might need to realign your wrist. In playing position there should be a straight line from the pinky base knuckle to your elbow. Even in higher positions there should be no sideways bending at the wrist. You might want to keep your elbow in a more neutral position, rather than so far to the right. If you don't have enough reach with a more natural rotation you might need more tilt to your setup (tilt the fiddle so the right side is lower than the left.)

You might want to spend some time integrating your hand and forearm, learn to use your steering mechanism. Your palm may be too close to the neck. Your wrist should be more or less straight. You may be grabbing with your fingers (flexors in the forearm) and pulling your palm up toward the neck. You want to start with good alignment and posture in the hand/wrist/forearm and throw the fingers from their base knuckles using the lumbricals, the intrinsic muscles of the hand.

January 18, 2015 at 01:00 AM · It hadn't occurred to me to consult a physical therapist, but I'll look into that. I don't really care of it's invasive or not, but I'll look into those threads as well.

I had stopped playing for some years, in part because it hurt to play, so unfortunately rest won't suffice.

I actually found that keeping my palm closer to the neck helped, and started doing this after my lapse in playing. I also started playing restless which helped.

I don't *think* I'm adducting my wrist when I'm playing, though it's possible that I did in the past. If I fully supinate my forearm, and flex my wrist that's roughly the position I play in when I'm higher up.

This is somewhat painful to do (especially supinating my forearm), but I need to additionally push on my thumb to torque my hand as if to further supinate my forearm to experience the sharp pain I get when I'm playing.

If I'm right about which tendon it is (and I'm less sure than ever at the moment), should adducting the wrist be painful?

January 18, 2015 at 01:41 AM · Supination is the rotation of the radius about the ulna. With palm open and facing you, that means the forefinger rotates away from you and around the pinky (clockwise from a birdseye view.) If you try to rotate the pinky around the forefinger you get a twisted flexion in the wrist (an adducting flexion) which could strain the pinky side of the wrist.

You might need a more open frame of the hand so the base knuckle of the first finger remains more extended by default. Establish a new finger pattern by placing 3 and reaching back with 2 and 1. Try coordinating the thumb to swing away as you supinate, rather than flexing forward. In high positions flex the thumb at its joint-closest-to-tip rather than from the ball of the thumb. Avoid swinging the thumb forward. Keep the ball of the thumb released and thumb open.

A few more questions:

Is your pinky much shorter than your middle finger?

Are your collar bones high set? If you hold a stick across your collar bones, how far below the stick are your shoulders? Are your shoulders wide? Is your upper arm relatively short?

You might want to tweak your setup so that everything adjusts to where your hand/wrist is most neutral and comfortable.

The first thing you might try is to move where your chin touches the fiddle. If your chin is close to or over the tailpiece your fiddle is rotated clockwise (from birdseye) which supinates your forearm. To undo that twist try holding the fiddle far to the left side of the left lower bout (Milstein.)

Try leaving your upper arm to the left side of the ribs instead of in front of your ribs (Ehnes.) These changes approach holding the violin more like a guitar. When going into high positions, rather than reaching up with your hand, drop the fiddle down to the level of your hand (even bending your torso a la Midori and Paganini.)

Tilting the fiddle (Oistrakh) as your default position allows you to keep the arm rotation more to the left and neutral and makes it easier for your fingers to reach. The disadvantage is for the bow arm when on the E string, for which you can turn your head left (Bell) to flatten the fiddle and bend left at the torso. With some planning and careful choreography you can make things a lot easier for your left hand.

Edit: in high positions check what's happening in your shoulder and biceps also. Muscles in a kinetic chain work synergistically, especially in order to fix joints. I don't remember which muscles do what, but for example, the biceps flex the elbow; but to really fix the elbow there are synergists in the forearm which kick in to inhibit the antagonists so you can get much stronger contractions. I think there are equivalent synergists for the wrist. So in high positions if you're pushing the shoulder forward and flexing your biceps hard, the flexion at your wrist might be much stronger than is necessary for playing thanks to synergy. Play in a high position and release just enough so that someone can remove the fiddle. Maintain your playing position as best you can. How curled in are you? Try the opposite: retract your shoulder, push your shoulder blade down and back, which naturally swings your elbow forward (pushing your shoulder forward does the opposite, swings your elbow back.) Try using pivot shifts, which is the opposite of arm shifts. In an arm shift your elbow swings right as you shift higher and pull your arm toward you. In a pivot shift your elbow swings left as you launch the shift up, which coordinates well with pushing your shoulder blade down and back. In this posture of the arm your lower trapezius is doing the most work leaving your biceps and flexors more relaxed, and you don't engage any synergists to stress the wrist.

January 18, 2015 at 02:05 AM · Greetings

-Try coordinating the thumb to swing away as you supinate, rather than flexing. In high positions flex the thumb at its joint-closest-to-tip rather than from the ball of the thumb. Avoid swing the thumb forward.

It is quite possible that what Jeewon is talking about here is indeed the basic cause of the problem. I have found it helpful to place the back of the hand on a table and supinate it by rolling the hand over the top of the pinkie which remains in place on the table. Repeat this action any number of times until you gave a clear sense of how it works. then try to swing them violin up using the same kind of rotation.

Best wishes,

Buri

ps Alexander lessons would prbaly help

January 18, 2015 at 08:35 PM · Some measurements, though they might be a bit rough:

My pink measures 7.5cm, while my middle finger measures 10.5cm.

In the area where my violin sits, it's about 4cm from my collar bone to the top of my shoulder.

My shoulders are about 50cm wide.

My upper arm is 32cm.

I'll keep these things in mind. I can definitely feel the difference on the ulnar side between Buri's table example and doing it the opposite way with my hand under the table.

I already hold the violin more to the left than to the center, and at a ~45 degree slant eyeballing it.

As far a the upper arm in high positions goes, it seems doable to leave it on the left of my ribs on the E string side, but as I approach the G string, it seems to demand quite a lot of my wrist.

I wonder if flatter fingers higher up wouldn't help as well? More reaching with the fingers, less with the wrist.

It's also seems likely that much of the problem is what I was doing in the past.

January 19, 2015 at 05:48 PM · Thanks for taking the measurements Mathew. I'm always curious how proportions affect setup and playing. I have a similar hand shape and high set collar bones, but shorter upper arms, which makes me have to be creative if I don't want to torque my arm under the fiddle so much.

It sounds like your hand shape might be the cause of the improper supination or over supination. To adapt hand posture to the pinky your stronger middle finger has to yield and curl much more, even leaning over toward the lower string. In high positions, if I need to keep my hand in frame, my middle finger curls over and touches the left side of the string in order for my pinky to be comfortable.

To keep my arm to the side when shifting high on the G string, I swing the fiddle left, i.e. bring the strings to my fingers rather than wrapping my arm around the fiddle. I know it's written in every book that we must keep the scroll high and strings level, but that hurts, and so is wrong for my proportions. I leave my palm at the level of my shoulder socket. Because of my high collar, raising the scroll so that the fingerboard (even the belly of the fiddle) is level causes unnecessary fatigue. I have also lowered the bottom end of the fiddle by holding it at the left side, and my chinrest/shoulder rest setup allows the fiddle to sit below my clavicle (I read somewhere Gingold suggested the same.) I made these changes for my shoulder, but all of this also serves to uncurl the whole arm and should also relieve the wrist, requiring less flexion and supination. Hope it helps!

January 19, 2015 at 10:26 PM · Re: the long middle finger with a short pinky.

In arpeggios and chords, I can't always press the string downwards, but rather sideways, towards the right, then pivoting into a better position as the chord progresses.

Also, high up on th E-string, I often find it unnecessary to hold the string right down the fingerboard.

January 20, 2015 at 03:32 PM · Hi,

A lot of material already... Just a couple of quick notes.

About James Ehnes and the arm/ribcage thing. I think this is misleading. James Ehnes plays with the elbow/upper arm pointing down, or rather in line with gravity. He also keeps it this way as he moves forward to the higher pitches. It is not that he is trying to keep it elsewhere. He simply doesn't rotate the elbow to the right the way we see many current players doing. Being in line with gravity by not rotating the elbow, even when going to the higher pitches, eliminates one of the biggest sources of tension there is, as well as improves accuracy. I would say that pressing the thumbs in either hands is the second biggest.

As for Oistrakh and tilting of the violin, it is normal for the violin to have some tilt for most players and to adapt in balance on the collarbone as one goes across the strings. The amount of tilt depends on the cushion one uses, chinrest, and the angle of the jaw/collarbone shape. As one goes to the g string, the violin will naturally pivot when one uses no SR or a cushion. In a way, the SR's chest portion reduces or eliminates this natural adaptation in balance to some extent.

In my experience the biggest sources of tension are:

1- raising the left shoulder to support the violin, or raise the collarbone to meet the chin/jaw.

2- rotating the left elbow to the right; the elbow should point down, not sideways.

3- pressing with the thumbs in either hand which contracts the hand. Basically, one should never press the thumbs. Joseph Silverstein once said very well that the moment the thumbs press against the instrument or bow, they become useless.

4- not being setup on the base of the first finger in the left hand with the thumb opposite coming up to its own natural height. Too many people force the thumb unnaturally low.

5- Overspreading the fingers on the right hand on the bow, which can cause a sympathetic tension on the left side. To be perfectly natural for one's body, the fingers should extended onto the bow at hand width. The degree of pronation, and to some extent the bow hold, depends on the length of the index and pinky. The shorter the index and longer the pinky, the more pronation there is, with the opposite being true as well.

Hope this helps!

Cheers!

P.S. Inflammation, aside from incorrect movements, is caused by diet in general and lack of exercise and sun, but that is a whole separate issue.

January 20, 2015 at 03:52 PM · Mathew, from what you describe, since it is an extensor issue, you might be having the most problems doing stretches with the 3rd and 4th finger? I agree completely with what Christian said above about the thumb. You want it to be light and relaxed. Some of my teachers have even had me practice without it as a drill. Ideally the thumb should not be moved too far back because when you do big stretches or extensions, with the fingers, the muscles and tendons in your hand will be fighting each other (if the thumb is too far back). It should ideally be more or less in line with the index finger or even more forward (depending on your hand structure).

This in my opinion is ideal hand positioning here in this picture of Mr. Heifetz playing in 3rd position: http://i.ytimg.com/vi/tpTAXRiJ85M/maxresdefault.jpg

I think it is great you are doing some weight training. Building some upper body strength can help combat these issues. I'm no doctor, but I've read that with some people, a diet high in carbs (bread, pasta, cake, cookies, soda, fruit juice etc.) can act as an inflammatory with the muscles and tendons. If you do eat lots of carbs maybe that can be something you experiment with reducing.

Good luck!

January 20, 2015 at 05:23 PM · I can relate to having pain and tendonosis. I've seen doctors, physical therapists, taken anti-inflammatory meds, various supplements, dietary changes, strength training...etc. None of this was very helpful, although I still take fish/krill oil, turmeric with oil and crushed pepper, magnesium malate, and other things.

Then someone recommended a certain massage therapist. The results have been amazing!!! I've only had 2 sessions so far, and my pain has been reduced by 90%. I can now play for 3 hrs. at a time. Where as before I had to rest every 10 min.

It's worth a try if what you are doing isn't working. But you have to find someone very knowledgeable in working out knots, ropes, scarred tendons, fascia problems etc.

January 20, 2015 at 09:49 PM · I second a good massage therapist for tendonitis. I have found doctors and medicines/pills/tablets to be useless for this condition.

January 21, 2015 at 11:10 PM · So, I've made several adjustments to my playing:

Playing with a straighter wrist, not swinging my arm around for high positions, defaulting to flatter fingers/stopping the strings with the pad, and holding my arm a bit more to the left. And just being generally very conscious of how much I'm supinating my wrist.

Overall, it felt more comfortable to play... but hours later, my wrist still feels very sensitive and painful. But maybe it'll aid with repairs.

It's worth clarifying I think that the issue here isn't inflammation, it's degraded/damaged tissue.

Nate:

If I left the third and fourth fingers out, It wouldn't certainly be easier to avoid over-supinating my wrist. I do play with my thumb between my first and second finger, and try to leave it as a passive shelf for the neck.

So far, I'm only doing weight training on the suspect tendon. I wish I could know for certain that it's even the damaged structure.

January 22, 2015 at 12:11 AM · Hi Matthew,

Glad you are feeling better!

Quickly - the left arm should not be to the left, it is simply that the elbow should point down, meaning that the upper arm should be perpendicular to the floor. Just as it is possible to rotate to the right as might be injurious, and exaggerated movement to the left will have the same effect. Also, as to the thumb placement, I will for once differ from Nate. To be perfectly natural for a hand, it should be opposite the base of the first finger, not the finger tip. Being too far forward can contract the hand which will force you bend the wrist to reach the third and fourth fingers.

Cheers and good luck!

January 24, 2015 at 06:47 PM · I'm not sure about the thumb being a "passive shelf": I prefer it to be sensitve, and active, even when immobile.

January 29, 2015 at 05:43 AM · So far my changes have been working better than I've expected. My wrist seems to only get somewhat sensitive, nothing that would impair me from practicing further.

I brought it up with my teacher after a couple months break, and I have her approval.

Christian,

To keep my thumb in line with the base of my first finger (relative to the neck of the violin), it seems I would either need to pull my thumb back unnaturally or supinate my wrist more.

Moving my arm more left also seems to lessen the amount of supination required. Of course it's possible to overdo it (although if you had it behind your back it could be totally neutral in terms of supination/pronation), but I don't think I am.

Adrian,

I've given what you said some thought. Besides supporting the violin, I suppose it's active in balancing it, feeling the position, and feeling the shift. Is there anything I'm missing?

January 29, 2015 at 07:32 AM · Hi Matthew,

Happy to hear that things are going better!

To answer your questions...

About the thumb, it depends on the violin and the length of string and your hand build which we cannot see. It may be somewhat more forward on a smaller instrument, like a Del Gésu, than an instrument with a longer string length like a long pattern Strad. The idea is not to force it too forward or back but have it natural for your hand.

As for the position of the left arm, again, its hard without seeing you, and depending on how your head is placed in relation to the chinrest as well as whether you hold the violin more forward, or more to the left, it will all look somewhat different. If one holds the violin more in front, then it will look more to the left of the ribcage then if one has the violin angled to be more open in line with the shoulder. Again, it's all a question of balance, as shoulder width and length of arms, along with other aspects of body structure determine angles that work for each body. The basic idea is to avoid over-rotating the arm to the right unnaturally.

It's always about balance and avoiding extremes. Extremes in any directions are always where we get in trouble, in my humble opinion. In the end, though there may be basic guidelines, it has to work for you.

Does this make more sense?

Cheers!

January 29, 2015 at 08:15 AM · Greetings,

here's something else to play with. Don't assume the violin s arse end stays in the same position under your jaw. Suppose you have a let mounted chin rest and a usual he's dposition.

Instead of this , when you get to a difficult passage of whatever, imagine you have an over he tail piece rest and slide the bottom of the violin more up the shoulder.. This has the effect of lining up the instrument and neck of the violin with your arm as it hangs straight down. Releases quite a lot of tension for some people.

Cheers,

Bur