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see also: Guitar Playing Part 2: The Aging Guitarist - Music and Medicine on Monday

content created August 2024 by Evgenia Molotkova BS

Approximately 16 million people (7% of the U.S. population ages 13-64) began to learn guitar over the two years preceding October 2021 - "citing COVID-19 and associated lockdowns as a major motivator" (Fender 2021)

 

53% of 105 guitar players (2 to 45 years experience) reported injury related to practice in a survey from Portugal (dos Santos 2024

       "Injury from practice" defined from one of three consequences: need to stop playing for one day; need to modify technique (reduced hours/intensity of practice); need to seek healthcare advice or treatment to address symptoms 

       Calculated as 1 injury per each 2,381 hours of practice.

       Failure to warm-up only variable statistically associated with increased risk of injury.

 

Description of Settings for Fender Telecaster Guitar (60 seconds)

Management of Finger Numbness and Tingling with Guitar Playing (60 seconds)

Management of Thumb Problems with Guitar Playing (60 seconds)

Use of Stents and Kinesio Tape to Adapt to Hand/Wrist Injury in Guitar Players (6 minutes)

Performance of "It Could Happen to You" with Discussion of Chord Melody and Improvisation

full video of interview and performance: 

 

Definitions

Repetitive Strain Injury (Cumulative trauma disorders): "injuries of the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions, vibrations, mechanical compression (pressing against hard surfaces), or sustained or awkward positions. injury of the musculoskeletal or nervous system caused by repetitive use, vibrations, compression or long periods in a fixed position" (McGreevey 2003)

PRMD = Playing Related Musculoskeletal Disorders: "defined as any weakness, numbness, pain, tingling or other symptoms that interfere with the ability to play a musical instrument at the level that the musician is accustomed to playing" (Portnoy 2022)

             Per Portnoy et al (2022):  Prevalence of PRMD in music students: 43-63%; among professional musicians: >80%

Ergonomics: "an applied science concerned with designing and arranging things people use so that the people and things interact most efficiently and safely" (Merriam-Webster 2024)

     also: "The field assesses labor efficiency, quality, quantity, and comfort to maximize these components while minimizing worker injury, turnover, fatigue, or overexertion ... recent studies have demonstrated the interrelationshiop between psychosocial factors and ergonomics" (Edwards 2024)

Overuse Syndrome: 'playing related pain, often accompanied by weakness, is caused predominantly by a focal inflammation and usually is unrelated to any systemic of psychiatric illness" (Rigg 2003)

Carpal Tunnel Syndrome - common among guitarists and other stringed instrument musicians who play with their wrists in flexion - caused by compression of the median nerve in the carapl tunnel leading to tingling, pain, numbness in the lateral 3 1/2 fingers

Cubital Tunnel Syndrome:  overall less common than carpal tunnel syndrome but has been reported to be the most common nerve entrapment syndrome in musicians (Szabo 2007)- is due to ulnar nerve entrapment or lack of nerve glide - ulnar nerve subject to stretch particluarly when the elbow is flexed.- usually involves fingers with ulnar nere supply  ( Pascarelli 2001)  Conservative treatment with splinting recommended by Szabo with surgery an option (Hoffmann 2006).

"Guitar tendonitis": inflammation of the tendons (tendonitiis) when occurring in wrists from overuse - called by some 'guitar tendonitis' (Shrestha 2011)

"Tennis Elbow" lateral epicondylitis - due to inflammatory process on the 'tumb edge' of the elbow (Shrestha 2011) - in guitarists may occur when gripping - most commonly while extending the hand at the wrist - often due to over-practicing and putting extra pressure on the fret board.

Musician's dystonia: defined by Waissman et al (2009) as a focal task-specific involuntary muscle contraction with loss of control of one or more digits of the hand while playing a musical instrument (see also Nishida 2023)

Focal dystonia (see You Tube video:  https://www.youtube.com/shorts/Tp_E-5HyY_s?feature=share): may occur in regions as unique as the lip (see: 'losing the lip') for brass instrumentalists, the voice as well as other sites not specific to musicians: (see: Facial Dystonia with Sialorrhea (Loss of Saliva or Drooling), Meige's Syndrome

Guitar string dermatitis: Multiple case reports:

       nickel allergy to guitar strings with dermatitis on tips,medial and lateral aspects of middle,ring and little fingers relieved by changing from nickel strings to 24-arate-gold strings (Marshman 1992); another report of a right handed guitar player who used a pick identified left handed rash, worst on left with patch testing showing strong reaction to nickel, cobalt, and chromium - resolution of the dermititis occurred when he switched to playing the drums; a second guitar player with similar allergies was unable to switch strings and continued to play with dermatitis (Smith 2005)

Guitar groin: pressure from guitar belly compressing the medial aspect of the thigh of a classical guitarist (age 24) from 4-6 hours of daily prctice in the sitting position with left leg fully flexed associated with stasis in the long saphenous vein and deep venous thrombosis of left calf and thigh. (Semple 1974)

Guitar nipple: traumatic mastitis of one breast reported in a series of three girls aged 8 to 10 years of age using a full-sized guitar with the dge of the soundbox pressed against the nipple - each was learning classical guitar with resolution of the inflammed cystic swelling at base of nipple when guitar playing stopped (Curtis 1974)

Arthritis - inflamation of a joint - not a single disease, but a group of many diseases that cause pain and limit join movement (multiple sources - see Arthritis References below)

Tendinopathy: a tendon condition associated with pain and swelling - considered by some as an umbrella term to identify injury to a tendon from overuse.  Some use it to include both tendinitis and tendinosis. The tendons are 'role-like tissues' attaching muscles to bone - (multiple sources - see Tendinopathy References below)

       Tendinitis - inflamation of tendons - 

       Tendinosis - breakdown of collage fibers in tendons - generally happens slowly; may result from tendon overuse

Background

Epidemiology

   Kok et al identified reports suggesting that up to half of musicians with musculoskeletal problems leave their careers as a result of these complaints (Kok 2013). In a more recent report, Kok et al (2023) identify the lack of prospective studies make numbers from surveys such as these difficult to interpret due to selection bias - and that 'exact and reliable numbers are missing due to the lack of prospective studies. "   

 61.3% (160 guitarists) identified 'playing-related pain' from a survey of 261 guitarists responding to 15 questions sent to professional, amateur, and student guitarists who play rock/blues,jazz and foldin the U.S. and Canada. (Rigg 2003). Most common reported site of pain was the fretting hand (41.8% =109 guitarists) reported playing related pain at this site in preceding 12 months.

                  also in the past 12 months 17.2% (45) identified back pain and 14.9% (39) reported neck pain associated with playing

   67.5% among 40 participants in an international guitar contest in Barcelona identified injury in the preceding 5 years most commonly cervical spine (27.5%), elbow/arm (22.5%) and wrist (20%).(Valenzuela-Gómez 2020)

    Reasons for musicians consulting Orthopedic hand surgeons (upper limb specialists) in Paris, France - 227 case files between 1994-2001 - 41% piano / 19% violin / 15% guitar - on average playing 4 hours per day.Thow-thirds presented with musculoskeletal disorders with signs of overuse (18%) or technique (8.8%) - with a surgical procedure proposed for only 19%( Nourissat 2003). These investigators identify a selection bias in that most were referred to this clinc from physical therapists and identify that problems with wind instruments more often consult Otolaryngology for ENT problems. More than half complained of pain with 17% "consulted simply for advice"  

Prevention

to address poor technique, inadequate supports, bad posture, overuse, misuse (Rigg 2003)

Warmup

Failure to warm up was the only statistically associated variable associated with increased prevalence of guitar-playing-injury identified in a detailed survey of 105 experienced guitarists (dos Santos 2024).  

(multiple referernces compiled including Miller/Sheresthra)

Warm and stretch your fingers for some time with easier stretches and motions before playing complicated and swift ones. During winters you can try warming up your arms and hands with a warm water soak or shower.
Don’t hang your guitar too low so that you need to flex your wrist more. Metal guitarists may look and encourage you but this type of playing style encourages injuries. Learn the basics correctly from reputable teachers, be it offline or online.
Avoid practicing and performing for lengthy period of time and take breaks in between.
Always try and keep your wrist as straight as comfortably possible.
Icing 20-30 minutes after prolonged effort will reduce inflammation and reduce potential damage.

Ergonomics

"With regard to the fretting hand, it was found that playing in a seated position rather than standing results in a statistically signficant lower rate of injury"  (Rigg 2003)

Classical guitarist addressed by Valenzuael-Gomez et al 2020) study of nine healthy classical guitar students - 

Treatment:

"Hand and upper extremity disorders of the musicians should not be treated surgically and guitarists are no exception. Surgery should always be considered a last resort" (Shrestha 2011)

Psychological support
Rest
Use of braces/splints

    a. 'Standard stack splint' for incomplete disruption of left ring finger extensor tendon (Lawton 1986)
Use of medicines, ice, vitamis, essential fatty acids, etc.
Use of muscle gel or deep heat

 

References 

note:  a PubMed (from the National Library of Medicine) search for the term "guitar" Sept 1, 2024  yielded 430 publications in the medical field addressing 'guitar' - selections from this source (as well as Google Scholar and other sources) are listed  below. "PubMed is a free resource supporting the search and retieval fo biomedial and life sciences literature" (<About - PubMed (nih.gov)  accessed 9 2 2024>) available since 1996, PubMed  was develope and is maintained by the National Center for Biotechnology Information (NCBI), at the U.S. National Library of Medicine,(NLM), located at the National Institutes of Health (NIH).

Valenzuela-Gómez SA, Rey-Galindo JA, Aceves-Gonzlez C. Analyzing working conditions for classical guitarists: Design guidelines for new supports and guitar positioning. Work. 2020;65(4):891-901. doi: 10.3233/WOR-203140. PMID: 32310218.

    citing information in Sanchez-Padilla M, Bayo-Tall´ on V, Esquirol-Caussa J, Guerrero-Forteza E,L´ opez-Iglesias I, Salas-G´ omez D. Inci dencia de lesiones en profesionales de la guitarra cl´ asica. Fisioterapia. 2013;35(6):243-51.

Johnson D. Classical Guitar and Playing-Related Muscu loskeletal Problems-A Systematic Review. 2009.

Marmaras N, Zarboutis N. Ergonomic redesign of the electric guitar. Appl Ergon. 1997 Feb;28(1):59-67. doi: 10.1016/s0003-6870(96)00032-4. PMID: 9414341.

Sulabh Shrestha: Guitar related hand injuries: Prevention and Treatment  on Medchrome Edical Online Magazine  June 23, 2011 <https://medchrome.com/extras/music/guitar-related-hand-injuries-preventi... accessed 8-31-2024)

 Johnny Miller: How To Take Care of Your Hands to Play Guitar [9 Tips] online Guitaresque January 4,2023 < https://guitaresque.com/how-to-take-care-of-your-hands-to-play-guitar/  accessed 8-31-2024>

Lawton MB, Asato V. Modification of a hand splint to permit playing of the guitar. Arch Phys Med Rehabil. 1986 May;67(5):342-3. PMID: 3707321.

Marshman G, Kennedy CT. Guitar-string dermatitis. Contact Dermatitis. 1992 Feb;26(2):134. doi: 10.1111/j.1600-0536.1992.tb00902.x. PMID: 1633705.

Rigg JL, Marrinan R, and Thomas MA: Playing-related Injury in Guitarists Playing Popular Music Medical Problems of Performing Artists, Volume 18, Number 4, 1 December 2003, pp. 150-152(3) Publisher: Science & Medicine, Inc. DOI: https://doi.org/10.21091/mppa.2003.4026 

    cited in Rigg et al:  Dawson W: Hand and Upper Extremity Problems in American Instrumentalists, J Hand Surg Br 24B (supp1):1, 1999

    cited in Rigg et al: Newmark J, Hochberg FH: Doctor, it hurts when I play: Painful disorders among instrumental musicians. Med Probl Perform Art 2:93–97,1987.

    cited in Rigg et al: Tubiana R, Chamagne P: Functional anatomy of the hand. Med ProblPerform Art 3:83–87, 1988

    cited in Rigg et al: Zetterberg C, Backlund H, Karlsson J, et al: Musculoskeletal problems among male and female music students. Med Probl Perform Art 13:160–166, 1998.

Volpe RL, Green MJ. Medical Schools Should Admit More Guitar Players. J Gen Intern Med. 2018 May;33(5):581-582. doi: 10.1007/s11606-018-4379-9. PMID: 29532301; PMCID: PMC5910368.

Semple R, Gillingham J. Musical Bumps. (letter re: 'guitarist groin') Br Med J 1974: 2: 504.

Thomas JM. Musical Bumps (letter re: 'guiar nipple') Br Med J 1974: 2: 504.

Curtis P. Guitar nipple. Br Med J 1974: 2: 226. (April 27)

Portnoy S, Cohen S, Ratzon NZ. Correlations between body postures and musculoskeletal pain in guitar players. PLoS One. 2022 Jan 4;17(1):e0262207. doi: 10.1371/journal.pone.0262207. PMID: 34982777; PMCID: PMC8726467. citing:

      Cruder C, Koufaki P, Barbero M, GleesonN.Alongitudinal investigation of the factors associated with increased RISk of playing-related musculoskeletal disorders in MUsic students (RISMUS): A study pro tocol. BMC Musculoskelet Disord. 2019; 20: 64. https://doi.org/10.1186/s12891-019-2440-4 PMID: 30736779

       KokLM,GroenewegenKA,HuisstedeBMA,NelissenRGHH,RietveldABM,HaitjemaS.Thehigh prevalence of playing-related musculoskeletal disorders (PRMDs) and its associated factors in amateur musicians playing in student orchestras: A crosssectional study. PLoS One. 2018;13. https://doi.org/10. 1371/journal.pone.0191772 PMID: 29444093

       Steinmetz A, Seidel W, MucheB.Impairment of postural stabilization systems in musicians with play ing-related musculoskeletal disorders. J Manipulative Physiol Ther. 2010; 33: 603–611. https://doi.org/ 10.1016/j.jmpt.2010.08.006 PMID: 21036282

       Steinmetz A, Scheffer I, Esmer E, Delank KS, PerozI. Frequency, severity and predictors of playing related musculoskeletal pain in professional orchestral musicians in Germany. Clin Rheumatol. 2015; 34: 965–973.https://doi.org/10.1007/s10067-013-2470-5 PMID: 24389813

       Gohil K, Sheth M,VyasN.Prevalenceofplaying related musculoskeletal disorders in musicians. Int J Ther Appl. 2016; 32: 100–103. https://doi.org/10.20530/ijta_32_100–103

Merriam Webster on-line dictionary defining 'Ergonomics' (<https://www.merriam-webster.com/dictionary/ergonomics  accessed 9-2-2024>)

Edwards C, Fortingo N, Franklin E. Ergonomics. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK580551/

Shah NA, Shimpi AP, Rairikar SA, Ashok S, Sancheti PK. Presence of scapular dysfunction in dominant shoulder of professional guitar players. Int J Occup Saf Ergon. 2016 Sep;22(3):422-5. doi: 10.1080/10803548.2016.1154720. Epub 2016 Mar 29. PMID: 27023289.

Smith VH, Charles-Holmes R, Bedlow A. Contact dermatitis in guitar players. Clin Exp Dermatol. 2006 Jan;31(1):143-5. doi: 10.1111/j.1365-2230.2005.01943.x. PMID: 16309515.

Friis UF, Menné T, Jellesen MS, Møller P, Verdingovas V, Jensen TR, Thyssen JP, Johansen JD. Allergic nickel dermatitis caused by playing the guitar: case report and assessment of nickel release from guitar strings. Contact Dermatitis. 2012 Aug;67(2):101-3. doi: 10.1111/j.1600-0536.2012.02043.x. PMID: 22775543.

Waissman F, Pereira JS, Nascimento OJ. Therapeutic immobilisation for small guitar player's dystonia: a case report. BMJ Case Rep. 2009;2009:bcr07.2008.0432. doi: 10.1136/bcr.07.2008.0432. Epub 2009 May 25. PMID: 21686815; PMCID: PMC3027575.

Zuhdi N, Chesky K, Surve S, Lee Y. Occupational Health Problems of Classical Guitarists. Med Probl Perform Art. 2020 Sep;35(3):167-179. doi: 10.21091/mppa.2020.3022. PMID: 32886734.

Zaza C. Playing-related musculoskeletal disorders in musicians: a systematic review of incidence and prevalence. CMAJ. 1998 Apr 21;158(8):1019-25. PMID: 9580730; PMCID: PMC1229223. [a systematic review addressing incidence and prevalenc of palying related msucoskeletal dirosrds in classically trained musicians]

Silva AG, Lã FM, Afreixo V. Pain prevalence in instrumental musicians: a systematic review. Med Probl Perform Art. 2015 Mar;30(1):8-19. doi: 10.21091/mppa.2015.1002. PMID: 25743601.

Zharinov GM, Anisimov VN. [Musics and longevity]. Adv Gerontol. 2014;27(2):284-90. Russian. PMID: 25306660.

Camporro D, González I, Martín C. Isolated second toe transfer after total amputation of the left fifth finger in a professional guitar player. J Hand Surg Eur Vol. 2014 Nov;39(9):1003-4. doi: 10.1177/1753193413508689. Epub 2013 Oct 14. PMID: 24127464.

McGreevey JE, Lacy Clifton R, and Kroll AG: Cumulative Trauma Diorders in Office Workers - "Public Employees Occupational Safety and Health Program of the New Jersey Department of Health and Senior Services" February 2003 (.Wayback Machine (archive.org) https://web.archive.org/web/20060723235917/http://www.state.nj.us/health... accessed 9-02-2024) 

Nakayama DK. Jazz Musicians and Their Disabilities: Django Reinhardt, Les Paul, and Michel Petrucciani. Am Surg. 2024 Jun 13:31348241259307. doi: 10.1177/00031348241259307. Epub ahead of print. PMID: 38869229.

Nishida D, Mizuno K, Takahashi O, Liu M, Tsuji T. Electrically Induced Sensory Trick in a Patient with Musician's Dystonia: A Case Report. Brain Sci. 2023 Jan 29;13(2):223. doi: 10.3390/brainsci13020223. PMID: 36831766; PMCID: PMC9954457.

Fender. Newsroom: "16 million Americans learned to play guitar in the last two years: Why and who are they?" [October 7, 2021]. Available from: <https://spotlight.fender.com/newsroom/news/844 accessed 09082024)

Pascarelli EF, Hsu YP. Understanding work-related upper extremity disorders: clinical findings in 485 computer users, musicians, and others. J Occup Rehabil. 2001 Mar;11(1):1-21. doi: 10.1023/a:1016647923501. PMID: 11706773.

Szabo RM, Kwak C. Natural history and conservative management of cubital tunnel syndrome. Hand Clin. 2007 Aug;23(3):311-8, v-vi. doi: 10.1016/j.hcl.2007.05.002. PMID: 17765583.

       Charness M. Unique upper extremity disorders of musicians. In: Millender L, Louis D, Simmons B, editors. Occupational disorders of the upper extremity. New York: Churchill Livingstone; 1992. p. 227–52 (cited by Szabo)

Hoffmann R, Siemionow M. The endoscopic management of cubital tunnel syndrome. J Hand Surg Br. 2006 Feb;31(1):23-9. doi: 10.1016/j.jhsb.2005.08.008. Epub 2005 Oct 12. PMID: 16225971.

Kok LM,  Van Noort A, and Nelissen RGHH:  Chapter 48 Musculoskeletal complaints in male and female instrumental musicians in Book: Principles of Gender-Specific Medicine Publisher: Elsevier Date:  2023

Kok L.M., Vlieland T.P.M.V., Fiocco M., Kaptein A.A., Nelissen R.G.H.H.: Musicians’ illness perceptions of musculoskeletal complaints. Clin Rheumatol 2013; 32:

Kok L.M., Nelissen R.G., Huisstede B.M.: The striking prevalence and alarming consequences of complaints of arm, neck and/or shoulder among music academy students – a comparative study. MPPA 2015; 30: pp. 163-168.

Arthritis References:

   The Free Dictionary by Farlex: "Arthritis" < https://medical-dictionary.thefreedictionary.com/arthritis accessed 9-8-2024>

   National Instiute of Arthritis and Muscoloskeletal and Skin Diseases (NIH) Nov 2022 <https://www.niams.nih.gov/health-topics/arthritis accessed 9-8-2024>

   Mayo Clinic webpage "Arthitis" < https://www.mayoclinic.org/diseases-conditions/arthritis/symptoms-causes... accessed 9-8-2024 >

Tendinopathy References: