Upper-extremity Problems Caused by
Playing Specific Instruments
William J. Dawson, M.D.
Abstract—This study was undertaken to obtain information on
the prevalence of music-related upper-extremity problems peculiar
to a specific instrument or group of closely-related instruments, and
to help determine what problem types are most common or charac-
teristic for players of specific instruments. Music-related problems in
167 performers from a hand surgical practice were reviewed retro-
spectively. The musicians ranged in age from 9 to 83 years; 41.9%
were males. Nearly 90% were professional performers, teachers, col-
legiate music students, or dedicated amateurs. More than 75%
played strings or keyboard instruments. Multiple diagnoses were
found in 37.7% of musicians. Data from the six largest instrumen-
tal groups revealed that muscle–tendon strain diagnoses were most
common, occurring principally among pianists, violinists and vio-
lists, guitarists, and reed instrumentalists. Other common diagnoses
included inflammatory disorders (tenosynovitis and the like), hyper-
mobility, masses, and arthritic problems. Of the pianists, 54.7%
developed strains, 17.4% inflammatory conditions, and 12.8%
nerve problems. Violinists and violists as a group had 64.4% strains
and 6.7% inflammatory conditions. Guitarists presented with
37.5% strains, 21.9% inflammatory conditions, and 15.6% nerve
problems. Flutists had 25% strains and 45% inflammatory condi-
tions. Other woodwind musicians developed 68.2% strains and
13.6% inflammatory conditions. Percussionists had 36.4% strains
and 36.4% inflammatory conditions. Only one musician developed
an upper-extremity problem that could be considered unique to
playing a specific instrument. Statistically significant occurrence
rates were found only in pianists under age 30 with strain diagnoses
and in those above age 30 with inflammatory problems. These cat-
egories seem to be related to repetitive and/or forceful upper-
extremity movements, and the resulting specific pathological
processes. Med Probl Perform Art 17:135–140, 2002.
D uring the past two decades, the arts medicine commu-
nity has accumulated much detailed and useful infor-
mation on the playing-related medical difficulties of instru-
mental musicians. A wide variety of presentations and
published articles have dealt with site-specific, disorder-spe-
cific, and instrument-specific topics; these reports were based
on a number of different research protocols and methods of
data collection. This information has resulted in the devel-
opment of more effective methods of diagnosis, treatment,
and prevention of musicians’ disorders.
Most of the current knowledge about music-related prob-
lems that are characteristic of, or unique to, specific instru-
Dr. Dawson is associate professor emeritus in the Department of Ortho-
paedic Surgery, Northwestern University Medical School, Chicago, Illinois.
Presented in part at the Twentieth Annual Symposium on Medical Prob-
lems of Musicians and Dancers, Aspen, Colorado, June 2002.
Address correspondence and reprint requests to: William J. Dawson, M.D.,
700 Woodmere Lane, Glenview, IL 60025-4469.
ments has been derived from early case reports 1-3 or from sur-
veys of performers.4-9 These surveys generally consisted of
reporting the performers’ subjective descriptions of physical
symptoms and their locations, and did not include specific
diagnoses made by health care professionals. Objective data
from an investigator’s clinical practice often have been
derived from specific study populations such as music stu-
dents, amateur players, and performers on specific instru-
ments5,10-13; other reports have focused on a single disease or
disorder and its instrument-specific prevalences.14-16 Addi-
tional articles, also based on clinical experience or research,
have reported on instrument-specific symptoms but have not
included specific diagnostic information.17 This relative lack
of published instrument-specific diagnostic data served as the
impetus for undertaking the current investigation.
This study attempted to provide some answers to two
questions: First, how common are upper extremity problems
that are peculiar or unique to a specific instrument or group
of closely-related instruments? Secondly, what music-related
upper-extremity problem types are most common or charac-
teristic for players of specific instruments?
MATERIALS AND METHODS
Data were obtained from the author’s university-affiliated
hand and upper extremity practice for the period 1984 to
1996, during which time a database of prospectively obtained
information was maintained on all musician patients in the
practice. Details of demographics, epidemiology, etiology,
diagnosis, treatment, and results were available for 1,354
instrumentalists with hand or upper-extremity problems that
had affected their musical performance. Music making was
reported to be the cause of difficulties in 167, or 12.3%, of
this population. All 167 patients comprised the current study
group; no musician was excluded. There were 70 males
(41.9%) and 97 females (58.1%), whose ages ranged from 9 to
83 years. As in prior reports by this author,18-19 musicians
were assigned to one of six classes according to their type and
degree of musical involvement (Table 1).
These performers played a wide variety of musical instru-
ments. Choir directors and band/orchestral conductors were
also included; all the directors played piano and therefore
were assigned arbitrarily to that instrument group, while the
conductors comprised a separate subset. Only six instru-
ments or closely-related groups contained more than 5% of
the total members in the study population; the others were
considered too small for their data to be statistically signifi-
September 2002 135
 TABLE 1. Musician Classes
Class Description
A Professional, mostly performance
B Professional, mostly teaching
C Conservatory or collegiate music major
D Active, dedicated amateur
E School musician, grades 2–12
F Amateur, recreational instrumentalist
cant. Therefore, most of the results have been derived from
these six groups.
The diagnostic categories used in this paper are similar to
those in some of the author’s other publications,18,19 which
employed the same database as the information source. The
term strain describes overuse-related or traumatic afflictions
of muscles, their tendons, and their attachments. Strains are
characterized by tearing of the muscle or tendon tissues, rang-
ing in severity from microscopic to gross separation of the
fibers. Pain is the most common symptom of strains, gener-
ally occurring at the point of injury; physical examination
confirms the presence of pain upon palpation of the injury
site, or by actively contracting or passively stretching the
involved muscle. Affected muscles in the hand and wrist may
be intrinsic (located entirely within the hand) or extrinsic (the
contractile or fleshy portion of the muscle is located proxi-
mal to the wrist and is attached to a tendon which inserts dis-
tally on the wrist or hand bones).
Sprain describes similar types of injuries occurring to liga-
ments about the joints. These also result in pain, both as a
symptom and a physical finding, and located over the injured
ligament. Inflammatory processes include inflammations of
tendons (tendinitis), of tendons and their synovial coverings
(tenosynovitis), and of the synovial lining of joints (synovitis).
These are grouped together, based on their similar etiologies
in this study, as well as on similarities in tissue responses.
Hypermobility, or the condition of nontraumatic excessive
joint range of motion, was determined using the criteria
established by Carter and Wilkinson.20
RESULTS
Table 2 compares the 167 musicians by class versus instru-
ment group. Keyboard and string instrumentalists together
accounted for 76.6% of the study group. Classes A, B, C, and
TABLE 2. Musicians by Class and Instrument Group
Group/Class A B
Keyboards 21 11
Strings 23 5 8
Woodwinds 12 1 8
Brasses 0 0
Percussion 5 0
Other 3 0
TOTAL 64 17
136 Medical Problems of Performing Artists
D comprised a subset whose musical involvement and activi-
ties have been described as “high-level”;21 this subset
accounted for 89.8% of the study group. Nine of the 11 class
E (regular school program) musicians played stringed instru-
ments, which seemed to be a relatively high prevalence for
this small cohort.
The following sections describe the results pertaining to
the six instruments or instrumental groups having the largest
numbers of patients. Table 3 presents a tabular view of the
individual data for all six groups.
Piano—58 Patients
This was the largest single instrumental group; the
patients’ ages ranged from 13 to 83 years, and more than
70% were female. They presented with a total of 86 separate
diagnoses, 23 pianists having more than one concurrent diag-
nosis at their first visit. Muscle strain was diagnosed 47 times
and comprised 54.7% of all diagnoses in this group. The 42
distally located strains were quite evenly divided among the
intrinsic muscles of the hands (14 patients), extrinsic flexors
of the fingers and wrists (13), and extrinsic extensors (15).
The laterality distribution of these problems was distinctly
uneven, however. Pianists’ right hands were involved in 20
cases (eight males, 12 females), their left hands in only five
(one male, four females), while the remaining 22 cases were
bilateral (five males, 17 females). Five additional patients
incurred strains of their cervical muscles.
There were 15 cases of inflammatory disorders, including
five patients with stenosing tenosynovitis of the finger flexor
tendons (“trigger finger”), three each with de Quervain’s
tenosynovitis and shoulder rotator cuff impingement or ten-
dinitis, and two others having epicondylitis at the origin of
the extrinsic flexor or extensor muscle groups about the
elbow. The right side was affected in seven patients (all
female), the left side in two (one of each gender), while bilat-
eral problems were diagnosed in six (two males, four females).
Nerve disorders were found 11 times in pianists, with
their right sides affected in four and bilateral involvement in
seven; all but two were in women. Eight patients had clinical
carpal tunnel syndrome (CTS), and seven of these also were
women. The frequency of CTS in this cohort was almost as
great as for all other instruments and groups combined (ten
musicians). Two others were diagnosed as having focal dysto-
nia involving their fingers.
C D E F Total
15 16 2 0 65
15 9 3 63
3 1 1 26
0 0 1 0 1
2 1 0 0 8
0 1 0 0 4
33 36 13 4 167
 TABLE 3. Diagnoses by Instrument or Group
No. Males/ Ages Sprain–Strain Inflammatory Nerve Other
Instrument Patients Females (Yr) Diagnoses Diagnoses Diagnoses Diagnoses
Piano 58 17/31 13–83 47/86 (54.7%) 15/86 (17.4%) 11/86 (12.8%) 13/86 (15.1%)
Upper strings 26 8/18 9–73 29/45 (64.4%) 3/45 (6.7%) 3/45 (6.7%) 10/45 (22.2%)
Guitar 24 20/4 12–77 12/32 (37.5%) 7/32 (21.9%) 5/32 (15.6%) 8/32 (25.0%)
Flute 13 1/12 16–53 5/20 (25.0%) 9/20 (45.0%) 4/20 (20.0%) 2/20 (10.0%)
Other woodwinds 13 6/7 17–62 15/22 (68.2%) 3/22 (13.6%) 2/22 (9.1%) 2/22 (9.1%)
Percussion 8 6/2 17–49 4/11 (36.4%) 4/11 (36.4%) 0 (0.0%) 3/11 (27.2%)

Other diagnostic groups included hypermobility, which
was recognized as a secondary condition in seven of these
patients, a frequency equal to that for all other instruments
or instrumental groups. In the remainder of these patients,
two had ganglia or other masses, one had joint laxity, and
three had joint stiffness or degenerative joint disease.
Pianists less than age 30 were much more likely to present
with strain problems (21/25) than inflammatory ones (2/25),
while those age 30 and older were less likely to do so (13/33
strain vs. 9/33 inflammatory). This difference between age
groups is statistically significant at the p < 0.001 level, based
on chi-square testing. All seven pianists diagnosed as having
hypermobility syndrome were age 30 or less; four were in
middle or secondary school and belonged to musician classes
D and E. The three youngest students also incurred strains of
their flexor or extensor groups about the wrist, while the
oldest (age 16) had a right-sided CTS.
Upper Strings—26 Patients
Violinists and violists were combined in this subset, based
on the similarities of holding and playing their instruments.
The 26 ranged in age from 9 to 73 years, and 69.2% were
female. Forty-five separate diagnoses were made, ten musi-
cians having more than one. Seventeen of the 26 patients
had muscle strains, and showed a distal limb distribution (six
intrinsic, eight flexor, and seven extensor) and percentages
similar to those of the pianists. Unlike the pianists, these
musicians’ left hands were involved more commonly. Right-
sided strains occurred in two men and one woman, left-sided
strains in two men and five women, and bilateral strains in
two men and five women. In addition, four musicians devel-
oped neck muscle strains and four strained their rotator cuff
muscle complex about the shoulder; of this group, two were
left-sided and two were bilateral.
Relatively few inflammatory and nerve problems were
seen (only three patients in each category, and no more than
one with any specific diagnosis), and only two musicians had
hypermobility syndrome. There was no significant age differ-
ential in the prevalence of either strain or inflammatory diag-
noses in this subset.
ilarity of instruments and playing techniques. A total of 32 dif-
ferent diagnoses were made, eight musicians initially present-
ing with more than one. Twelve patients developed muscle
strains, all of which occurred in males and were located distal
to the elbow. Right-sided problems were diagnosed in two
men, left-sided in five, and bilateral in an additional five; three
muscle strains were in the intrinsic muscles, four in the flexors,
and five in the extensors. Seven guitarists (four of them males)
incurred tenosynovitis of the wrist or fingers, but no more
than two had involvement of the same anatomical location.
Right and left sides were equally involved, with three patients
in each category; one other had bilateral difficulties.
Five neurological diagnoses were made, including three
musicians with CTS and two with focal dystonia in the hand
or fingers. Three additional guitarists developed wrist ganglia
that affected their playing (this number represented 60% of
all patients diagnosed as having ganglia), while the other five
presented with a miscellany of different playing-related diag-
noses. As was found with the upper bowed strings, there was
no significant age differential in the prevalence of either
strain or inflammatory diagnoses in this subset.
Flute—13 Patients
These musicians’ ages ranged from 17 to 62 years; all but
one were female. They presented with a total of 20 diagnoses,
seven performers having more than one at the initial visit.
This was the only instrument whose players’ inflammatory
diagnoses outnumbered muscle strains (nine to five); three of
the nine were de Quervain’s tenosynovitis at the wrist, two
were trigger digits, and an additional three were located prox-
imal to the forearm. Five of the nine inflammatory condi-
tions were left-sided, while four were on the right. Four of the
five patients with muscle strains had involvement of their
wrist and finger flexors or extensors, while the other devel-
oped rotator cuff difficulties. Strains were left-sided in two
cases, right-sided in one, and bilateral in two. Two of the four
nerve entrapments were CTS. Two flutists also were diag-
nosed as having hypermobility syndrome. No difference in
prevalence by age was noted in this subset, regarding the
major diagnostic groups.

Guitar—24 Patients Other Woodwinds—13 Patients

These patients had an age range from 12 to 77 years; 83.3% This cohort includes all players of single and double reed
were males. One bass guitarist was included, based on the sim- instruments, as well as recorder; all these instruments have

September 2002 137

relatively similar embouchures (vs. flute and/or brass) and
techniques of support, distinctly different from the flute.
Clarinetists were the most numerous (5/13). The musicians
ranged in age from 17 to 62 years and included six males and
seven females. They presented with a total of 22 diagnoses,
seven musicians having more than one. They had the highest
prevalence of muscle strain problems (15/22), all of which
were distal to the elbow. Four of the 15 had intrinsic strains,
five had extrinsic flexor group involvement, and six had prob-
lems with their extrinsic extensors. Only three inflammatory
conditions were noted; all were tenosynovitis of the hand or
wrist and did not occur in clarinetists or oboists. Two cases of
CTS were found, and hypermobility was diagnosed in one
performer, a 43-year-old female professional clarinetist. No
difference in prevalence by age of diagnostic types was noted
in this subset, either.
Percussion—8 Patients
This was the smallest of the six groups, with an age range
of 17 to 49 years, and was composed of six males and two
females. Only three of the eight presented with more than
one concomitant problem, resulting in a total of 11 diag-
noses. There were four cases of muscle strain, three of which
involved the extrinsic extensors of the wrist or fingers. An
additional four patients had inflammatory disorders, only
one of which involved the shoulder. Considering these small
numbers, it is not possible to determine valid age prevalences
for the major diagnostic groups.
Conductors—4 Patients
This group also is far too small to provide any valid statis-
tics, and thus was not included among the cohorts described
above. Nonetheless, it is of interest to note that all four devel-
oped problems with their shoulders (two right, one bilateral)
or elbow (one right), very likely as a result of their conduct-
ing activities over many years. The group included three
males and one female, and ranged in age from 57 to 67 years,
a span well within the usual age range for developing degen-
erative tendinitis and similar attritional difficulties.22
DISCUSSION
This study is based on patients actually seen and evalu-
ated, and with specific diagnoses made, not on the subjective
responses returned by a group of surveyed instrumentalists.
Keyboard and string musicians comprised 76.6% of the study
group, a figure similar to that for the author’s entire experi-
ence with 1,354 musicians (78.9%), and as reported by
others. Brass instrumentalists traditionally have been less
likely to experience music-related upper-extremity problems
than other musicians,6 but the one patient found in the cur-
rent study represents a much lower prevalence than reported
by any other investigators, whether from a survey or based on
clinical experience. The reason(s) for this underrepresenta-
tion are yet to be determined, but perhaps may be related to
138 Medical Problems of Performing Artists
such factors as referral patterns to the author’s practice, the
location of the practice, or insurance matters.
Patients in all six instrumental groups having relatively
large numbers of players developed the same types of playing-
related physical problems. Muscle–tendon strains, inflamma-
tory conditions, and neurological problems comprised the
majority of diagnoses made among all 167 musicians, with
variability noted among the six subsets. The relatively higher
prevalence rates of certain anatomical areas seem to reflect
the biomechanics and ergonomics of playing specific instru-
ments. For example, holding and playing the violin and viola
produced more problems at the neck and shoulder regions,
while single and double reed instrumentalists experienced
more difficulties with their hands, wrists, and forearms. All
seven diagnoses recorded in clarinetists and oboists were
strains or sprains; four involved the right hand or forearm,
while three were bilateral. Since right hand difficulties may
be related to supporting these instruments, the observed
high prevalence may be significant, but not at a statistical
level. However, only one clarinetist had a specific right
thumb problem—chronic strain and laxity of the ulnar collat-
eral ligament at the metacarpophalangeal joint—that might
be a direct result of holding the instrument. Flutists in par-
ticular had a relatively high prevalence of de Quervain’s
tenosynovitis, perhaps related to the high degree of wrist
extension and radial deviation needed to hold the instru-
ment.23 No other diagnoses could be directly attributable to
instrument support. Rapid and repetitive finger motions, so
necessary for playing any instrument, include not only flex-
ion and extension, but also lateral spread and, in some
instances, rotation; for all these motions, the intrinsic mus-
cles of the hand play the greatest functional role. This fact
may account for the high frequency of intrinsic strain in the
current study.
Only one musician presented with a physical problem
than might be considered unique or peculiar to a single
instrument or group. A professional bassoonist was diag-
nosed as having a strain of the left wrist flexors, and this was
felt to result from reed-making activities (holding the reed
firmly in the nondominant left hand while working on it
with tools held in the right hand).1 Since professional oboists
and bassoonists may spend as many as 20 hours weekly
making reeds, the causal assumption seems valid.
Data on the laterality of upper-limb problems conform in
general to those published by other investigators.6,16 Pianists
had their right side involved 34 times and the left 11 times;
however, 25 demonstrated bilateral difficulties. The right-
sided preponderance was greater in musicians with
sprains/strains, rather than in inflammatory disorders.
Violin, viola, and guitar players demonstrated the expected
left-sided preponderance of strains, with a left/right ratio of
more than 2:1; however, more than half the upper string
cohort experienced bilateral problems. All other instrument
groups either had no significant laterality difference or were
too small to obtain significance.
Gender differences among the musicians also were in con-
formity. In the current study, males comprised 62% of the
group, in comparison to Fry’s figure of 55%. Nonetheless,
the author’s percentage of male upper string players was 30%
compared with Fry’s figure of 55%16; the discrepancy likely
reflects the greater number of orchestral musicians in his
study. Relative gender rates for muscle strains in both pianists
and upper string players parallel the rates for the entire
cohort, but pianists with inflammatory conditions were 80%
female, while the entire piano cohort was only 71% female.
Pianists were the only group of musicians who showed any
significant relationship of age to prevalence of problem type.
This finding may be based partly on the relatively small num-
bers of other instrumentalists, which prevented drawing any
statistically significant conclusions.
Individual tissues respond to trauma or repetitive stress in
limited and specific ways, and many different types of stress
may produce a single type of pathological response. Instru-
mentalists’ postural and repetitive upper-extremity activities
primarily affect the musculoskeletal system—joint surfaces,
ligaments, muscles, and tendons—and it seems logical that
these structures would be the source of specific problems
such as tendinitis, tenosynovitis, and muscle strain.
Half the patients diagnosed as having benign hypermobility
syndrome were pianists, but this prevalence rate was lower than
that for both upper string players and flutists. The condition
was not found in guitarists, even though the 20 male members
of this cohort had a mean age of 34 years. The reasons for these
findings remain obscure, although issues could be raised about
the study group’s being a convenience sample or the effect of
musician self-selection to play a particular instrument. The cur-
rent data are insufficient to answer the question of whether
hypermobility is an asset to instrumentalists or a possible con-
tributing factor to playing-related problems.
Multiple different diagnoses were frequent in this study;
63 (37.7%) presented with more than one, and the total of
143 conditions averaged 2.3 per patient. The most common
combination of diagnoses found was multiple muscle strains,
involving either intrinsics and extrinsics, flexors and exten-
sors, or a combination of all these. Hypermobility was always
found as a secondary diagnosis. With the exception of organ-
ists and choir directors, CTS (when occurring as one of mul-
tiple conditions) was always accompanied by either strains or
inflammatory conditions. It must be noted that five patients
were diagnosed as having CTS as a solitary condition.
Comparing the results of this study with those of other
investigators is difficult, since differences exist in patient pop-
ulations, study designs, and terminologies. Fry’s 1988 study16
comes closest in comparison, although it is significantly larger
and is based on a purely referral population. He describes
only right- and left-sided problems in his subjects, not bilateral
ones (did any of his patients suffer from bilateral difficulties?).
Unlike the current study, Fry includes focal dystonia in his
category of overuse, but excludes inflammatory diagnoses.
The data in this study are highly dependent on the demo-
graphics of the study group. The current 167 musicians were
part of a general hand care/surgery practice; they encom-
passed all ages and all degrees of both musical skill and
involvement. These facts may explain the relatively low per-
centage of musicians in the author’s practice who attributed
their problems to playing, as well as to the relatively low per-
centage of neurological diagnoses made. It is very likely that
specialists in other fields of medicine would report different
prevalence data, reflecting the composition of their specific
practices. Determination of true prevalence rates would
require obtaining data from a large series of practices, encom-
passing a wide spectrum of medical specialists and extending
over long periods of time (at least a decade). These data
would permit construction of a meta-analysis that could
supply the needed information, but it would still suffer from
the differences in terminology among the authors.24,25 The
difficulty of obtaining instrument-specific incidence rates is
even greater, as only a very few practitioners have a controlled
patient population that would provide valid longitudinal
studies.10,13
CONCLUSIONS
Playing-related hand and upper-extremity problems are
common among instrumentalists and tend to fall into spe-
cific diagnostic categories. However, these categories are not
specific or unique to any one instrument or related group of
instruments, but occur among all instrumentalists. The
majority of problems seem to reflect the effects of repetitive
and/or forceful upper-extremity movements on the body’s tis-
sues and the resulting specific pathological processes. The
biomechanical requirements and ergonomic characteristics
of specific instruments seem to play a role in determining the
etiology, nature, and anatomical location of musicians’
upper-extremity problems. Strains of the muscle–tendon unit
predominated in the study group and are the most common
diagnoses made among pianists, guitarists, upper string play-
ers, and reed instrumentalists. Inflammations about tendons
and joints are most common in flutists, while percussionists
and orchestral conductors show equal prevalences of the two
groups (although the latter group has a predilection to shoul-
der difficulties). Nerve impingement syndromes and dystonia
are relatively less common, although more prevalent among
flutists and guitarists than in the other groups. Hypermobil-
ity is more likely to be diagnosed in young performers, and
always as a secondary diagnosis. Instrument-unique problems
were distinctly uncommon in this study group.
Information from this study may prove useful to both
music educators and instrumental teachers, especially help-
ing them to be aware of potential music-related problem areas
in their pupils. Health care professionals may use these data
to obtain greater diagnostic precision and efficiency with
their instrumentalist patients.
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