Steven Liu, MD, and Gregory F. Hayden, MD


South Med J. 2002;95(7) 

In This Article

The String Section: Violin, Viola, Cello, and Bass

A common skin condition experienced by violinists and violists at both the amateur and professional level is "fiddler's neck," an area of hyperpigmentation and lichenification on the left side of the neck, below the angle of the jaw. Erythema, scaling, cyst formation, scarring, and inflammatory papules or pustules also occur.[18,19] Focal neck edema can lead to concerns about the cosmetic appearance or even malignancy.[19] These skin changes have been attributed to a number of factors, including poor technique leading to increased pressure of the instrument on the skin of the neck, increased friction between the instrument and the skin caused by a poorly fitting chin rest or an inadequate shoulder rest, poor hygiene, and even the size of the instrument. Viola players may be more prone to have fiddler's neck than violinists because the instrument is larger and heavier.[18] Holding the violin or viola in a more horizontal, less "drooping" position can often correct the edema of fiddler's neck.[19]

Although a cellist would never have fiddler's neck because of the obvious differences in instrument position, similar conditions have been described. "Cellist's chest" was seen in a cellist who presented with tenderness, hyperpigmentation, erythema, and edema in the region of the sternum.[9] This region of her chest would press tightly against the cello while she played. "Cello knee" was noted in some cellists who had erythema, scaling, calluses, or hyperpigmentation over the medial aspect of the left knee, in the region that would contact the cello during playing.[9] Even a "cello scrotum" has been described, though its occurrence has been questioned.[20,21]

Chin rest allergy may produce findings similar to those in fiddler's neck. Hypersensitivity to the chin rest of a violin or viola can produce localized eczema in the regions of the left chin and cheek in contact with the chin rest. Chin rests made of East Indian rosewood (Dalbergia latifolia) or Brazilian rosewood (Dalbergia nigra) have been implicated.[22,23] Boxtree wood (Buxus sempervirens) has been recommended as an alternative chin rest wood because it does not contain any known contact allergens.[24] Even if the wood of the chin rest does not cause an allergy, the chin rest stain may elicit an allergic response. Chin rests made of ebony wood that are not sufficiently black have been colored with a stain containing "Ursol-Echtschwarz," which consists of paraphenylenediamine, a common allergen.[24]

Allergic sensitization in a string player is usually due to rosin (colophony) that is applied to the bows of string instruments in order to increase the grip of the bow on the string.[10] Rosin dust can induce dermatitis of the fingers and hands, as well as the face and neck. There are many brands of rosin with various compositions, so symptomatic string players should find a different rosin that is better tolerated. Rosin is not the only cause of finger dermatitis in string players, however. Finger dermatitis caused by allergy to a violin string has been reported in a violinist who had an allergy to chromate and whose E-string was composed of a chromated steel core.[25]

String players often have calluses on the tips of their left-hand fingers due to repetitive trauma from depressing the strings. String instrument playing may also lead to skin thickenings that mimic rheumatologic findings. Garrod's pads are skin and tissue thickenings over the interphalangeal joints that can mimic Heberden's and Bouchard's nodes. Professional violinists have been reported to have Garrod's pads isolated to the proximal interphalangeal joints on the middle and index fingers of the left hand (the fingering hand). The formation of these pads has been considered a protective mechanism to strengthen the skin and subcutaneous tissues above the extensor tendon that comes under great tension from forceful application of the fingers onto the violin strings.[26]

In string players, both hands may be affected by overuse syndrome. The flexors and extensors of the right hand are used to control the bow and can be affected. The muscles that hold the left hand in ulnar deviation, as well as those that spread the fingers are also frequently affected. The neck and shoulder may be affected because of the prolonged unusual position of the head and neck used to hold the violin.[11]

Because the violin and viola are held underneath the left side of the mandible, players of these instruments can be predisposed to jaw disorders. Violin and viola players often report signs and symptoms identical to those of temporomandibular joint (TMJ) pain dysfunction syndrome. They report an increased frequency of pain and noise in the TMJ area as compared with a control population.[27] Mandibular movement is more limited in these musicians, and there is increased rightward deviation of the mandible on opening. Symptomatic violinists and violists can alter their technique to reduce the force on the mandible by the instrument and thereby minimize pain and dysfunction.[27]

String players are at risk for entrapment neuropathies and are sensitive to mild neurologic deficits. Predisposing factors include compression by hypertrophied forearm muscles, anoxia due to venous congestion caused by pressure, traction on neural tissue because of awkward playing posture, or friction trauma from repetitive motion.[2] Carpal tunnel syndrome has been cited most frequently, but compression of the digital nerves from gripping the bow too tightly has also been reported.[28,29] Ulnar neuropathies in violinists and violists result from constant flexion of the left elbow while holding the instrument.[28] Radial neuropathies have also been reported; the posterior interosseus branch of the radial nerve can become entrapped beneath the arcade of Frohse, though this theory is not universally supported.[30,31]

Focal dystonias have been described as localized involuntary motor movements that interfere with the ability to perform.[12] They may consist of abnormal spasms or posturing of isolated muscle groups that may become apparent only during playing.[2] Musicians often report incoordination while playing, frequently accompanied by involuntary flexion or extension of fingers during music passages that emphasize rapid, forceful finger movements.[11] The problem generally affects musicians who are well into their careers, and it is highly refractory to treatment.[12] String players with focal dystonias will typically have the disorder in the left hand (the fingering hand) where fine motor coordination is essential.[32]