Upper extremity disorders in performing artists - cont.

world-class career awaits them if they practice, when this may not be the case.

Tendinitis, tendon trauma, and overuse injuries
Tendinitis is a misused and overused term that does not truly point to an underlying pathologic condition. In the past. this constellation of problems has been called tenovaginitis, peritendinitis, tenosynovitis, intersection syndrome, deQuervain 's syndrome, trigger finger, epicondylitis, rotator cuff impingement, repetitive strain disorder, cumulative trauma disorder, and tendon overuse injuries. These eponyms confuse patients and healthcare providers. Recent anatomic and pathologic studies classify this general condition into various Subtypes:10

1. Peritendinitis describes an inflammation of the epitenon (outer layer of the tendon and its investing synovial sheath). The tissues present with local swelling, pain, crepitation, warmth, or generalized dysfunction.
2. Peritendinitis with tendinosis adds intratendonous degeneration with loss of collagen fiber orientation, scattered vascular ingrowth without obvious tendon inflammation, and tendon nodules.
3. Tendinosis describes intratendonous degeneration due to aging of microtrauma. It is noninflammatory and may present with nodule formation. This represents a loss of normal collagen fiber orientation and increased cellularity. This is also noted as mucoid degeneration.
4. Tendinitis is symptomatic tendon degeneration with an inflammatory response. This may be acute, subacute, or chronic, and can superimpose underlying tendinosis.
In any given situation, several processes may be operating at once. Patients present symptoms of focal pain, snapping, popping, swelling, tenderness. diminished dexterity , and occasional erythema. Initially, symptoms are mild and usually ignored. Symptoms may appear only during execution of specific techniques, such as seen in pianists playing octaves, chords, trills, and arpeggios. These involve wide finger stretches or chronic repetitive activity . Violinists or violists playing in higher positions require long finger stretches, chronic repetitive finger movement with the wrist in maximal flexion, supination, and ulnar deviation. Vibrato accentuates the problem. Symptoms frequently begin in the dorsum of the wrist and forearm, the origin of the extensor carpi radialis brevis at the lateral epicondyle of the humerus (tennis elbow), and the fIrst dorsal extensor compartment known as deQuervain 's syndrom.
Dorothy Taubmanll described a scenario in pianists in which digital extensors may be affected because the hand is too close to the keyboard, necessitating metacarpophalangeal hyperextension with each finger stroke, which causes fatigue most commonly in the ring finger. On the flexor surface, digital flexors peritendinitis and tendinosis may cause painful digital or thumb triggering, although poor conditioning in athletes has been mentioned as a factor in tendon injury . In athletes, there are no objective criteria; the condition is probably multi-factorial, having much to do with underlying tendon composition and duration and intensity of overload.

 In 1986, Fry graded symptoms in five stages: 12
. Stage I. Pain at one site that is induced by playing and ceases after stopping
. Stage 2. Pain induced by playing, associated with weakness and loss of control
. Stage 3. Pain persisting after playing and induced by
other activities .
. Stage 4. Pain with activities of daily living
. Stage 5. Severe pain with no function
Performing artists may find themselves canceling performances, shortening practice times, and exhibiting serious deterioration in the ability to play. In many instances this problem may be self -limiting, but a significant number of days, months, or even years may pass before the musician seeks help. By this time, the patient is in deep despair.

Treatment or overuse injuries
As indicated by Fry12 in 1986, treatment includes rest from all activities that initiate or perpetuate pain. This may include reducing the playing schedule and modifying harmful practice and performance techniques. The amount and quantity of rest may relate to the severity of symptoms. Initially, rest may include a short period of splinting, systemic or topical anti-inflammatories, and physical therapy that may emphasize thermal modalities, heat or ice, or iontophoresis. A program of stretching and strengthening exercises should begin very gently and slowly. Gentle passive, active, and active-assist range of motion exercises should slowly progress to resistive exercises. In selected refractory cases, local cortisone injection may be indicated. Rarely, surgery may be required. Modifications to activities of daily living are helpful. Some activities unrelated to performance perpetuate symptoms. A common aspect of physical training is the performance of specific exercises to stretch out the muscle-tendon complexes most involved in a given activity.
The efficacy of a muscle-stretching regimen to prevent injury and increaseefficiencyofperformance has been well demonstrated by athletes.13 The same is undoubtedly true for musicians. Stretching increases muscle flexibility, maintains range of motion, and increases the strength of the musculotendinous unit, permitting it to more efficiently store energy and contract Itis critical to return to playing slowly. Earlyoveruse can be detrimental physically and psychologically and may ultimately delay return to full performance.
It has been well shown in the laboratory that immobilization deconditions muscles, tendons, and ligaments. Human muscle biopsy studies show that type I muscle fibers atrophy with immobilization.14 Their cross section decreases, and the potential for oxidative enzyme :lctivity is reduced. Aerobic capacity of the muscle fibers rapidly decreases. primarily in fiber types affected by the chosen sport. For example, type I (slow twitch) fibers are affected in marathon runners, while type II (fast twitch) fibers are affected in athletes engaged in activities that require Speed.15 The same is true for performing artists.
Maryland Medical Journal March 1993
257
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