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Carpel
Tunnel Syndrome
(c) 2004 by Dr. Timothy Jameson Doctor of Chiropractic
Castro Valley, CA
A common problem among both acoustic and electric guitar
players, as well as other stringed instrument players,
is the development of forearm pain, tingling, and numbness,
typically on the same side that you fret the instrument.
This column will explain a specific type of repetitive
injury called cubital tunnel syndrome, which affects
the inner side of the forearm and the pinky side of
the hand. Most musicians are probably not familiar with
this syndrome even though the symptoms are experienced
by many. The typical presentation of the syndrome, the
anatomical structures involved, along with prevention
and treatment options will be discussed in this article.
Cubital Tunnel Syndrome typically involves pain and/or
abnormal sensations in the elbow area, along the inner
side of the forearm. The pain can travel downwards towards
the pinky, and can be accompanied by tingling or numbness
sensations to the pinky side of the hand. The forearm
muscles can be achy, sore and painful, and can lead
to a misdiagnosis of tendonitis by an inexperienced
doctor.
This syndrome usually only involves the ring and pinky
fingers, since these fingers receive their nerve supply
from the ulnar nerve. Some variations in the nerve supply
to the fingers may allow for the middle finger to be
involved as well. The ulnar nerve begins from nerve
fibers exiting from the spine in the neck, called the
cervical spine. The nerve traverses down the arm, passing
through the "funny bone" area of the elbow, then travels
down the outer side of the forearm to hand muscles along
with the 4th, and 5th fingers. The purpose of the nerve
is to allow for communication between the brain and
hand, allowing for both motor control of the hand, and
sending sensation from the hand to the brain.
If the syndrome progresses, it can lead to decreased
function of the hand, especially grip strength. It is
common also to experience tingling and numbness in the
fourth and fifth fingers. Wasting or atrophy of the
pad of muscles on the palm side below the pinky finger
can develop as well. Typically, the person notices that
flexing the forearm tends to irritate the symptoms.
Another symptom is the musician beginning to notice
that he/she cannot control the fourth and fifth fingers
very well. It's as if they're trying to control finger
motion, but the hand just is not receiving the signals
and has a œmind of its own.” Loss of dexterity, speed,
and control of the ring and pinky fingers is a hallmark
sign of this syndrome.
The culprit in this syndrome is compression of the ulnar
nerve. Just south of the elbow, the nerve passes through
the flexor carpi ulnaris muscle to travel down to the
hand. A small tunnel forms in this location, and the
nerve becomes surrounded on all sides. In this tunnel,
the ulnar nerve sits on top of the flexor digitorum
profundus muscle. A ligament forms the top layer of
the tunnel. It is important to understand the function
of the muscles in this tunnel, because they play a major
role in the development of the syndrome. The flexor
carpi ulnaris muscle attaches to the inner part of the
elbow, and its function is to flex the wrist and move
the wrist inward towards the pinky. The flexor digitorum
profundus attaches to the medial elbow and inserts into
the tips of the fingers. This muscle's function is to
flex the fingers (especially the tips).
Now that you've survived the anatomy lesson, let's discuss
in real life how these anatomical structures are affected
with guitar playing. As I stated earlier, this syndrome
typically affects guitarists in the fretting hand, so
in a right handed guitarist, the left hand is typically
involved. If we dissect the playing of a simple barre
chord, we would notice 1) contraction of the thumb against
the underside of the neck of the guitar, 2) a counterbalancing
contraction of the opposing fingers on the top fretted
side of the neck, 3) bending of the fingertips to push
against the strings, 4) flattening of one finger against
the neck to form the bar (usually the first finger),
4) maybe some stretching of the pinky to reach a higher
fret and 5) flexion of the wrist.
Since the ulnar nerve passes between the muscles that
perform flexion of the wrist, bending of the fingertips
and stretching the pinky to reach the higher frets can
irritate the muscles surrounding this nerve. With constant
overuse of these muscles, they can become inflammed,
or actually form "microtears" at the attachments to
the elbow. This is especially evident in guitarists
who have not developed strength in their forearm musculature
in preparation of hours of practice time. The swelling
involved can start squeezing down on the ulnar nerve,
causing the symptoms mentioned above. This is also why
bending the forearm will worsen the complaints. The
ulnar nerve becomes stretched upon flexion of the elbow.
If the nerve already is being pinched, the stretching
is going to amplify the symptoms.
Cubital tunnel syndrome can also occur from other maladies,
such as traumatic injuries to the elbow from car accidents,
falls, elbow fractures, and elbow dislocations. Many
musicians also do computer work on the side, and repeated
keyboarding at the computer with poor posture and little
rest time, and constantly leaning on their elbows while
at the computer can predispose the musician to ulnar
nerve problems. Overall poor health of the musician
is a complicating factor as well. Not exercising, poor
nutritional intake, alcohol and drug consumption, and
preexisting health conditions can weaken the body to
make is more susceptible to neurological insult.
A very important cause of CTS that must not be overlooked
is neck problems. Since the nerve fibers that travel
to the hand must first exit the spine, any problems
with the cervical spine in that vicinity will irritate
the nerves. For example, if you have suffered a whiplash
injury from a car accident " even years previously "
it can predispose you to cubital tunnel syndrome. Chronically
bad posture and forward head tilt can also lead to nerve
compression. Consider your posture while playing your
musical instrument. How many guitarists do you see in
a forward head posture, leaning over the axe, while
playing difficult passages? How about shredders who
are flailing their heads back and forth while playing
their high-speed arpeggios? Chronic poor posture exerts
tremendous strain not just on the neck, but upon the
entire spine and nervous system. Unfortunately in a
majority of cases, you will never experience actual
discomfort in the neck with cubital tunnel syndrome.
ItÆs important to note that only a Doctor of Chiropractic
can determine if the neck is the source of your problem.
Physical therapists and medical doctors do not receive
training in locating and correcting spinal subluxations
" the misalignments that irritate and distort nerve
function.
For those of you who do not have the symptoms mentioned
and would like to prevent them from ever occurring,
there are a few simple steps to take:
1) Give yourself more frequent breaks (about a 10 minute
break after every 45 minutes of playing) during rehearsing
or practice times. The constant playing for hours upon
hours without resting can lead to microtearing of the
muscles and the resulting repetitive strain.
2) Before you play and during your breaks, increase
blood flow to the forearm and hands by stretching and
performing self-massage to the area. (You may want to
visit your library or bookstore and look into some massage
techniques - these help to increase the blood flow to
your arms and flush out toxins.)
3) Begin receiving regular massages by a professional
massage therapist to keep your muscles supple and relaxed.
4) Have an evaluation by a doctor of chiropractic to
make sure the alignment of your neck, shoulders, and
elbows is correct, allowing proper nerve flow to the
muscles of your hands.
5) Enhance your nutrition and use nutritional supplements
so your body has all the building blocks need to cellular
repair and nerve transmission.
6) Begin and/or maintain a weight training regimen that
concentrates not only on the major muscle groups, but
the forearm and hand muscles as well. The stronger those
muscles are, the less chance of fatigue and injury.
If you do have the symptoms mentioned in this article:
1) If you simply have some forearm muscle soreness,
use heat on the forearm before practicing, and ice the
elbow and forearm area after playing. The heat will
encourage more blood to the tissues while playing, and
the ice will discourage swelling afterwards. Perform
stretching to the forearm three to four times daily.
2) If you are experiencing nerve related symptoms like
tingling and numbness, burning sensations, muscle fatigue,
and lack of coordination of the fingers, see a Doctor
of Chiropractic immediately who is experienced in treating
musician's injuries. Many musicians make the mistake
of seeing their general medical practitioner who is
not trained in caring for repetitive strain injuries.
Most musicians who go the medical route receive dangerous
medications that may actually worsen your condition.
Even something as simple as ibuprofen can damage the
kidneys and liver. With this in mind, do not become
an anti-inflammatory junkie. Repeated use of antiinflammatories
will simply mask a more serious underlying problem,
and can lead to organ problems.
3) Always try conservative measures first, such as chiropractic,
massage therapy, or acupuncture. Give yourself at least
six to eight weeks to heal.
4) If you notice symptoms worsening, or weakness occurring
in the hands, even with the conservative care programs
provided to you with chiropractic and massage, your
health care provider should refer you to a neurologist
for a consultation and neurological testing. In my experience
in working with musicians via chiropractic care, this
rarely happens. I would estimate 90% of patients who
present to my office with these symptoms overcome them
with natural, conservative chiropractic wellness care,
and become healthier, more creative musicians in the
long run.
Finally, donÆt œhope the problem with go away.” If you
are a guitarist or musician of any instrument, and begin
noticing changes in the function of your hands, do not
wait to have them evaluated. The faster you receive
care for them, the faster they will heal. Musicians
who put off receiving treatment for cubital tunnel syndrome
risk the more serious consequences of hand muscle wasting,
numbness, loss of ability to play their instrument,
and chronic disability. Treat your body as a temple,
and care for it daily.
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Biography of
Dr. Timothy Jameson, D.C., C.C.S.P.
Dr. Timothy Jameson is a 1984 graduate of Syracuse University
with a Bachelor of Science degree in Biology. He continued
his postgraduate education at Los Angeles Chiropractic
College, and graduated with honors as a Doctor of Chiropractic
in December of 1988. Upon graduation, Dr. Jameson worked
in a busy practice in New Jersey for one year, then
moved to California in 1990, where he married and started
his own Chiropractic practice. His wife, Dr. Laurie
Gossett, is also a chiropractor as well as a Bradley
natural childbirth educator. In 1992, Dr. Jameson completed
a 300 hour postgraduate program in the diagnosis, treatment,
and rehabilitation of sports injuries, and became certified
as a Chiropractic Sports Physician by the American Chiropractic
Association.
Over the past few years, Dr. Jameson has channeled his
energies towards the treatment and rehabilitation of
repetitive strain injuries, also known as cumulative
trauma disorders. He recently completed a book entitled
"Repetitive Strain Injuries: The Complete Guide to Alternative
Treatments and Prevention," which is now available in
bookstores across America. The publishing company is
Keats Publishing in New Canaan, Connecticut.
Besides chiropractic, Dr. Jameson enjoys music, and
is a pianist and guitarist. This has led him to work
with musicians who suffer from RSIs. (See web page:
http://www.gbase.com/chiro/ for musician-related RSI
articles.)
Dr. Jameson enjoys lecturing on the topics of repetitive
strain injury prevention techniques and ergonomic principles
to businesses who want to take a proactive approach
to injury prevention for their employees. If you are
interested in this service, please email Dr. Jameson
at the address mentioned in this web page. Dr. Jameson
also responds to your RSI-related questions via e-mail.
E-mail Dr. Jameson at Chiro4U@aol.com.
Dr. Jameson can be contacted at the two California offices
listed below or via e-mail.
Bayshore Chiropractic Holistic Health Center
3319 Castro Valley Blvd.
Castro Valley, CA 94546
510-582-5454
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