Monday, September 11, 2017

Marimba Body: Aching Elbows

As we gear up for fall and the concert season ahead, whether as a student, professor, or touring artist, it's a good time to reflect on our technical habits.  For those that took time off over the summer, there's the process of re-integrating hours of practice. For those that are preparing entire new programs (ehhem...yours truly), there's the challenge of not rushing through the learning process, mentally and physically. 

Throughout my time writing the Marimba Body series, folks have approached me with different questions of "do you have anything about ___?"  Coming up a few times is the issue of elbow pain - what it is, how we get it, and how to heal and then prevent it. 

Here's what I've learned, experienced, and found.

Three Common Pain Areas

Most commonly, percussionists experience elbow pain:
- on the outside of the elbow (lateral epicondylitis, aka: tennis elbow)
- on the inside of the elbow (medial epicondylitis, aka: golfer's elbow)
- at the back of the elbow (posterior impingement or triceps tendonitis)

Lateral Epicondylitis

Symptoms: tenderness and perhaps pain around the lateral epicondyle (bony bit outside the elbow);
          weakness when gripping small objects, such as mallets;
          weakness and tenderness when supinating the forearm (rotating outwards, as in to play mallet 2 or 3)

Causes: excessive use of the forearm that strains muscles;
          repetitive twisting of the wrist and forearm

Related to activities like writing, typing, playing instruments (guitar, violin, percussion, etc), painting, racquet sports (especially backhands)

Definition: inflammation at the attachment of the Extensor carpi radialis brevis (the muscle that extends the wrist, ie: during an upstroke) and humerus at the lateral epicondyle

Healing: go easy, and don't try to "play through" the ache, as it could result in a tear, as the drawing above shows;
          ice the area if it helps;
          apply a compression wrap

Awareness and Prevention: pay close attention to tightening the elbow during passages of tremolos, quick tempi, and large leaps - pause and relax the area before playing the passage again, focusing on a different physical sensation in the elbow than the time before

Medial Epicondylitis

Symptoms: slow-growing tenderness and pain at the medial epicondyle (bony bit on the inside of the elbow);
          pain while pronating the wrist (using the inside mallet on a surface too low for your height);
          tenderness during wrist flexion;
          numbness in 4th and 5th fingers

Causes: gripping a small object for long period of time (like mallets or sticks);
          repetitive wrist flexion

Related to activities like golfing, maxing-out with free weights, rock climbing, squeezing and rotating an object (ie: doorknob)

Definition: inflammation at the attachment of Flexor pronator muscles and humerus at the medial epicondyle

Healing: take a break from the painful activity;
          ice the area if it helps;
          begin therapeutic stretches and exercises as soon as possible

Awareness and Prevention: pay close attention to holding mallets or sticks tighter than necessary;
          when working on fast finger strokes, focus on a relaxed elbow and neutral shoulder

Posterior Impingement

Symptoms: pain and tenderness at the back of the elbow when the arm straightens;
          sensitivity to touch at the back of the elbow

Causes: activities that repetitively straighten the elbow while adding sideways pressure

Related to activities like pitching, martial arts, repetitive throwing, locking elbows during planks, or reaching for a note in an upper or lower octave from the elbow instead of the center of the body

Definition: compression and damage to soft tissues at the back of the elbow due to excessive extension

Healing: take a break from the painful activity;
          begin therapeutic stretches and exercises as soon as possible     
*Unlike the other injuries, posterior impingement is usually not damage to a tendon, and may take longer to heal.
Awareness and Prevention: take care that the instrument is the correct height;
          in sports activities, keep a slight bend in the elbow to prevent hyperextension

Triceps Tendonitis

Symptoms: pain at the back of the elbow when pushing against resistance;
          back of the elbow is sensitive to touch

Causes: forceful pushing, throwing, pressing as in a push-up (or applying too much tricep pressure during a stroke)

Related to activities like bench presses, pushing heavy objects, or push-ups without proper support from the shoulder and back

Definition: inflammation of the attachment of the tricep to the ulna at the olecranon process (bony bit at the back and bottom of the elbow)

Healing: stop the painful activity;
          ice the area, and use a compression brace if helpful;
          elevate the elbow

Awareness and Prevention: pay attention to not applying too much downward pressure with each stroke, especially during tremolos, rolls, and loud passages;
          when leaning against a table during study or meals, keep the back of the elbow relaxed
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In conversations with different players, it seems that aching elbows most often occur in the non-dominant arm, while shoulder pains (especially at the insertion of the bicep) most often occur in the dominant arm.  This is just anecdotal evidence I've collected, but it would be interesting to investigate in a more formal way.

My hunch as to why it could happen is connected to my theories that improper shoulder alignment causes pain down below, as I talked about during my PASIC 2015 presentation.  Without proper support from above the elbow joint, the strength needed is dispersed to smaller muscles below the joint, hence the gradual appearance of aches and pains.
- - - - -
Sports Injury Clinic
Mayo Clinic
Hand and Wrist Institute
New York Orthopedics

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