Maladies in Musicians

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

South Med J. 2002;95(7) 

Abstract and Introduction

Abstract

Certain medical ailments occur with increased frequency among musicians and can affect musicians of all ages and ability. These maladies range in severity from incidental, asymptomatic findings among casual and occasional players to serious injuries that significantly disable professional musicians from practicing or performing. The most prevalent problems involve overuse of muscles resulting from repetitive movements of playing, often in combination with prolonged weight bearing in an awkward position. Other common problems include dermatologic irritation, peripheral neuropathies, focal dystonias, and otolaryngologic disorders. This review organizes the musical maladies according to section of the orchestra with further subclassification by pathologic process. By becoming familiar with the disorders associated with specific instruments, physicians will be better able to make the correct diagnosis in musicians with medical complaints.

Certain medical disorders occur with increased frequency among persons working in particular occupations (ie, mesothelioma among asbestos workers). In similar fashion, other medical disorders occur with increased frequency among persons with certain avocations (ie, tendinitis at the lateral epicondyle among tennis players). Since playing a musical instrument can be either an occupation or an avocation, it should perhaps come as no surprise that certain medical ailments occur with increased frequency among musicians. The study of performing arts medicine can be traced as far back as the early 1700s when the Italian physician Bernardino Ramazzini summarized the occupational diseases of musicians.[1] As time has passed, the awareness of medical conditions associated with music playing has grown, so that today there are clinics that specialize in the care of musicians' ailments and there is even a journal, Medical Problems of Performing Artists, devoted to the subject.

Maladies in musicians may range in severity from an incidental asymptomatic finding in a casual and occasional player to a serious injury that significantly disables a professional musician from practicing or performing. The most prevalent medical problems among musicians relate to overuse of muscles involved in the repetitive movements of playing, often in combination with prolonged weight bearing in an awkward position.[2] The term overuse syndrome is often used generically to describe all types of tendinitis, tenosynovitis, dystonia, and related conditions.[3] Overuse syndromes are caused by excessive or unaccustomed use, are characterized by pain and loss of function in muscle units, and are manifested by weakness, loss of control (accuracy), and loss of agility (speed).[4] This problem has been associated with increased time and intensity of practicing, a predisposing musculoskeletal condition at baseline, and overly tense technique. The pain is sometimes preceded by feelings of stiffness, tingling, or abnormal skin sensations. Rest is the only reliable treatment for overuse syndromes. Symptomatic measures such as anti-inflammatory drugs, muscle relaxants, counseling, acupuncture, and psychotherapy do not reliably improve the course of the disorder.[5]

Another medical concern common to musicians of all kinds is hearing loss. Rock musicians who play at high decibel levels are at greatest risk. However, playing any instrument in an orchestra and being exposed to loud noises made by other instruments could place even these quieter musicians at risk for hearing loss. The literature has shown conflicting conclusions about this hypothesis, although the overall opinion seems to be that noise-induced hearing loss does occur in orchestral musicians.[6] Positioning within an orchestra may have an impact on hearing loss, since some studies have shown that violinists have greater hearing deficits in the left ear, which receives more orchestral noise than the right.[7] Earplugs are problematic, as they can interfere with communication during rehearsals, and orchestra players often need to listen closely to the other instruments during an orchestral piece. Some orchestras raise the brass and percussion players to a higher level on stage to lessen the sound pressure levels reaching the ears of the players seated in front of them, reducing or eliminating the need for earplugs.[8]

Other maladies in musicians often have common pathologic mechanisms, such as dermatologic irritation or performance anxiety, and may therefore be common to more than one instrument. Previous reviews have therefore focused on a specific pathologic process.[2,4,9-17] There are often distinct differences among the disease characteristics induced by various instruments, however, so this paper will organize the musical maladies according to section of the orchestra, with further subclassification by pathologic process. Greater familiarity with the medical conditions associated with music playing will help physicians to make the correct diagnosis in a musician with a complaint. Musicians usually understand that their conditions are impeding their music-making, but they sometimes fail to appreciate that the conditions are actually a direct result of their instrument use. This important insight may facilitate the diagnosis and treatment of their conditions.

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]

The Wind Instruments: Flute, Piccolo, Clarinet, Oboe, Bassoon, and Saxophone

Several cases of "clarinetist's cheilitis" have been described.[33,34] One case involved a 15-year-old girl who had recently changed from a polystyrene reed to a cane reed (Arrundo donax) because she preferred the tonal quality of the wood reed.[33] She subsequently had redness and scaling of the median portion of the lower lip, corresponding to the distribution of the cane reed. Patch testing showed no evidence of cutaneous hypersensitivity, and the cheilitis was thought to have been caused by irritant contact factors. The patient was advised to switch back to the polystyrene reed.

Much like clarinetist's cheilitis, saxophonists have also been described as having cheilitis from their reed. One saxophonist had slight eczema on his central lower lip, not spreading beyond the vermilion border, exactly where his lip would contact his cane reed. He showed a positive scratch test with fine saxophone reed scrapings and was treated with 1% hydrocortisone acetate cream with good results.[35]

"Flautist's chin" has been described and is similar to fiddler's neck. A 32-year-old amateur flautist presented with an eruption of acneiform lesions and hyperpigmentation confined to the central midportion of her chin, where she was in contact with her flute.[36] Wetting of the chin with saliva or breath condensate was suspected as a predisposing factor, as this slipperiness could cause the player to increase the pressure of the flute against the skin.[36,37] Flutes are often made of alloys containing multiple metals including nickel, so the reaction could also have resulted from a sensitivity to nickel.[37] In one report, an amateur flautist with flautist's chin had a positive patch test to nickel, so it appears that flautist's chin can be caused by mechanical irritation, metal allergy, or a combination of the two.[38]

Overuse syndromes in wind players usually present differently from those in string players. In flute players, the right shoulder is the most common problem area because of its abducted, externally rotated position when the flute is played. In clarinet, oboe, and English horn players, the static loading of the web-space muscles between the thumb and index finger used to support the instrument predisposes them to overuse problems.[39]

Changes in the construction of wind instruments during the 19th century affected the prevalence of overuse syndrome in wind players.[40] In the early 1800s, the clarinet was usually made of a light boxwood, weighed about 300 g, and was held with both hands. Overuse syndrome in clarinetists was not reported during this time. However, after the boxwood was replaced with grenadilla (a heavy hardwood) and heavy keywork was added, the 20th century clarinet weighed about 830 g. Because of this increased weight, the clarinet could not be held comfortably by the two hands and was loaded onto the right thumb with a thumb rest. Overuse syndromes in clarinetists appear to have arisen as a result of these changes. Conversely, changes in the construction of flutes have probably lowered the prevalence of overuse syndrome in flute players. The 19th century flute was made of wood and was heavier than the modern flute made of metal. For this reason, overuse syndrome in flute players is likely to be less common now than in the 19th century.

In addition to peripheral mononeuropathies, cranial mononeuropathies have also been reported in wind players.[28] An oboist had numbness of the upper lip after intensive practicing and was found to have sensory loss in the distribution of labial branches of the trigeminal nerve. Similarly, a clarinetist had trigeminal neuralgia in a maxillary distribution that was almost exclusively triggered by playing the clarinet.[28]

Clarinetists playing scale passages have manifested focal dystonias with involuntary third finger extension and fourth and fifth finger flexion, predominantly of the right hand.[41] This incoordination made trills more difficult for the clarinetists.

The high intraoral pressures required to play wind instruments may cause a variety of otolaryngologic disorders. A 23-year-old oboe player was found to have velopharyngeal incompetence after complaining of a 6-year history of "nasal snorting" that would begin after 10 minutes of continued playing. The incompetence would only manifest itself while she played the oboe.[42] This type of disorder could potentially ruin careers in music, because oboists are often required to play long phrases without taking a breath. With air leakage associated with an incompetent palate, the musician loses air reserves more quickly and is forced to break the musical phrase more often to take another breath.[43] Velopharyngeal insufficiency has also been reported in a concert bassoonist who failed orchestra auditions because of a clearly audible "noise coming from her head" while playing the bassoon.[44] Rest and palatal exercises have been used to treat stress velopharyngeal insufficiency, though surgical options can include endoscopic posterior pharyngeal augmentation with Teflon injection or a surgically created pharyngeal flap.[45]

Another otolaryngologic disorder associated with increased intraoral pressures from wind instruments is laryngocele, an abnormal enlargement of the saccule of a laryngeal ventricle. Laryngoceles are generally filled with air, and are termed internal when limited to the interior of the larynx or external when they protrude laterally into the neck. Wind and brass players are at increased risk for laryngoceles; one report showed laryngoceles in 52 (56%) of 93 of band members studied.[46] Since none of the laryngoceles in these musicians caused symptoms, no treatment was advocated.

The playing of high-resistance wind and brass instruments such as the oboe, bassoon, French horn, and trumpet has been associated with increases in intraocular pressure and greater incidence of visual field loss. The Valsalva maneuver associated with high-resistance instrument playing is thought to be responsible, because it causes a rise in intrathoracic pressure and compression of the intrathoracic venous system. This leads to vascular engorgement, increased choroidal volume, and a rise in intraocular pressure. The cumulative effects of long-term intermittent intraocular pressure may result in glaucomatous damage.[47]

The Brass Section: Trumpet, French Horn, Trombone, and Tuba

Like flute players, trumpet players with nickel allergies have had hypersensitivity reactions to their instruments. Eczema in the lip area has been described in trumpet players with positive patch tests to nickel sulfate. These nickel-related conditions have resolved after the musicians switched to gold or plastic mouthpieces.[48,49]

Players of brass instruments must form an embouchure (the positioning of the mouth, facial muscles, tongue, and jaw such that the lips will vibrate when blown through). The lips of brass players are subject to high pressures; it takes strength and agility of the lip musculature to maintain the proper embouchure. Both higher and louder notes require greater pressures, translating to greater stresses on the lip musculature.[50] The high stress from the combination of prolonged playing, high notes, and fortissimo intensity predisposes brass players to lip muscle injury.[51]

An example of such an injury is rupture of the orbicularis oris, also known as "Satchmo's syndrome." Trumpet players are most vulnerable because of the high pressures required to play the trumpet, but players of other brass instruments such as the French horn or trombone are also affected. This injury results in a decline in the strength and agility of the lip musculature with weakness during pouting and an inability to maintain high notes. Some trumpet players with Satchmo's syndrome have been treated surgically with success, though prolonged rest is another treatment alternative.[50] In fact, this syndrome is named for Louis Armstrong because it matched the symptoms he experienced in his lips in 1935 that forced him to stop playing the trumpet for 1 year.[50,52]

Because brass instruments place great demands on the muscles of the face and tongue, dystonias of these muscles can severely impair a brass player's ability to play. Cases of "embouchure dystonia" have been reported in French horn players whose lips would involuntarily separate, producing a gap in the air seal.[53] These players improved somewhat with muscle retraining and technique alteration.

Like most other instrumentalists, brass players are subject to entrapment neuropathies and dystonias, but they also have more serious neurologic risks resulting from the elevated intrapharyngeal, intrathoracic, and intra-abdominal pressures. A 17-year-old trumpet player had transient ischemic attacks during intensive trumpet playing.[54] He was found to have a patent foramen ovale, and Doppler ultrasonography showed increased rates of microembolic signals in the middle cerebral arteries during trumpet playing and Valsalva maneuver. An increase in positive end-expiratory pressure may occur in brass players and would increase the cardiac right-to-left shunt fraction, thus causing embolization.[54,55] After the patient had the foramen ovale operatively closed, the symptoms disappeared and no microembolic signals could be detected, even during Valsalva maneuver.[54] A second example involves a 23-year-old trumpet player who had a spontaneous cervicothoracic epidural hematoma after a professional trumpet performance.[56]

As in wind instruments, the intraoral pressures generated during playing of brass instruments can be extremely high, and otolaryngologic disorders such as stress velopharyngeal incompetence and laryngoceles can be manifested. A 17-year-old trumpet player had velopharyngeal incompetence while attending band camp, where he practiced 8 to 10 hours per day, approximately four times his usual practice duration.[45] Nasal air escape developed during instrument play, as well as nasal regurgitation of liquids and hypernasal speech. Rest and palatal exercises were prescribed, and his condition improved.

A 16-year-old trumpet player was found to have bilateral laryngoceles after his band leader noticed a left neck mass that developed during playing.[57] Physical examination showed a 6 cm air-filled mass in the left side of the neck with forced expiration against a closed mouth and nasopharynx. Surgery was deferred while the laryngocele remained reducible and asymptomatic, and the boy was allowed to continue playing.

Several studies have examined the relationship between French horn playing and cardiovascular conditions. In one study, 37 (49%) of 75 French horn players had a wandering atrial pacemaker while playing, and one had second-degree AV block of the Wenckebach type, suggesting that "musical athletes" may possess unusually sensitive vagal reflexes.[58] A second study described a 47-year-old French horn player with essential hypertension who had immediate increases in diastolic pressure when playing, especially when playing higher notes.[59] Fortunately, other studies have found no correlation between horn playing and hypertension.[60,61]

Miscellaneous Instruments: Drums, Guitar, Harp, and Piano

Three musicians learning to play the classical guitar have had traumatic mastitis of one breast, referred to as "guitar nipple."[62] The soundbox of the guitar pressing against the breast was thought to have induced inflammation around the nipple base. The mastitis subsided with the cessation of guitar playing. Similar to violin-string dermatitis, a case of guitar-string dermatitis was reported in a patient with a nickel allergy.[63] Paronychiae have been identified as important occupational hazards to pianists and harpists, and harpists frequently develop finger calluses, onycholysis, and subungual hemorrhages.[10]

Overuse syndrome can affect keyboard players at the wrist and finger extensors, the lumbricals (especially the fourth and fifth digits) of both hands, and the interossei of the right hand.[39] Developments in musical instrument technology during the 19th century had great impact on the prevalence of overuse syndromes in pianists, because the newer pianos were constructed so that significantly greater weight was needed to depress each key, requiring the player to use more muscle power.[40]

Median nerve neuropathy distinct from carpal tunnel syndrome has been reported in a harpist whose symptoms were triggered by forceful pronation of the forearm associated with tuning several harps during a series of concerts.[28]

Although focal dystonias have been de-scribed in a wide variety of musicians, keyboard players appear to be the most commonly affected.[12] Pianists with focal dystonias often follow a pattern of involuntary flexion of the fourth and fifth fingers of the right hand.[41] The right hand of a pianist plays the melody more often than the left, so it is often required to be more dynamic. A pattern of involuntary flexion of the third finger has been reported in guitarists with focal dystonias. This affliction in the right (plucking) hand interferes with a guitarist's ability to extend the finger in preparation for another plucking motion.[41]

Conclusion

Medical problems are a significant problem not only in professional musicians, but also in musicians of all ages and ability. By becoming familiar with the known disorders associated with specific instruments, physicians will be better able to identify and treat musicians who have conditions affecting their performance. Awareness among musicians needs to be raised as well, since proper technique and conditioning may prevent potentially career-ending disorders from developing. Further research might clarify unclear issues such as the frequency of noise-induced hearing loss in orchestra players and the causes of focal dystonias. Research in medical engineering could also be applied to instrument construction in hopes of lowering the incidence of certain instrument-related injuries. Lighter weight instruments with new designs promoting more comfortable playing positions could decrease the incidence of overuse syndrome or entrapment neuropathies and could provide alternatives for affected musicians. We hope that medical progress will be able to take the sour notes out of making sweet music.

Sidebar: Key Points

  • Certain medical ailments occur with increased frequency among musicians and can affect musicians of all ages and ability.

  • The most prevalent problems involve overuse of muscles resulting from repetitive movements of playing, often in combination with prolonged weight bearing in an awkward position.

  • Other common problems include dermatologic irritation, peripheral neuropathies, focal dystonias, and otolaryngologic disorders.

  • By becoming familiar with the disorders associated with specific instruments, physicians will be better able to make the correct diagnosis in musicians with medical complaints.

  • Musicians usually understand that their conditions are impeding their music-making, but they sometimes fail to appreciate that the conditions are actually a direct result of their instrument use.

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