Ligaments, Tendons and Bumps, Oh My!

A 20 year old piano major approached me about two months ago because she was experiencing some disturbing symptoms and was wondering if I could help her.  Amy wasn't having any discernible problem playing but her plaint was when she woke up in the morning or in the middle of the night, her three middle fingers were stiff, almost locked and painful.  After she slowly flexed them a few times they were fine and they didn't give her any problems until the next morning.  Her teacher was assigning several difficult works for her to study and forcing her to play with flat fingers so I took about ten minutes to feel her hands and fingers and immediately knew what her problem was. 

Our tendons are made up of thousands of fibers all neatly bundled together, those bundles are bundled, then those bundles are bundled several times over and finally the entire massed bundle makes up a tendon about the size of a linguini and the tendon as a whole is protected in a lubricated sheath where it can glide back and forth effortlessly. 

Think of the tendon as a plastic, polypropylene, polyester or nylon braided rope.  The single rope as a whole is actually made up of thousands of smaller fibers making the whole greater than the individual parts.  Every hiker, camper or construction worker knows that when you cut one of these ropes you need to finish off the ends by melting or burning it.  This creates a little knot of melted materiel and prevents the rope from fraying.  Likewise, as the rope is used, stretched, dragged over edges and exposed to friction, along the path of the rope there will be fraying.  Shakespeare said it nicely, "Take but degree away, untune that string, And, hark, what discord follows!"  Conversely, allow a rope to constantly fray, And hark, what discord follows. 

The body repairs frayed tendons much the same, by putting little knots of scar tissue where damage has occurred.  Doctors often refer to these knots as nodules.  They can be quite painful and can eventually cause the finger to lock up.  Laymen will refer this symptom as "trigger finger."  Picture a sweater with a hole in it.  If you were to sew up the hole, there would be a little knot there.  Although the hole is now healed, the sweater won't wear as effortless as it used to.  Every thread in a sweater is connected to every other thread and every movement will pull on that knot.  That is why diagnosing hand issues is so difficult.  The pain may be in the forearm but that is where the tissue is giving way because there is a knot in the palm.

When you flex your flexor muscles in your forearm, your muscles pull your long flexor tendon which is attached all the way to the tip of your finger and your finger bends.  If there is a little knot or nodule anywhere in the sheath, usually near a joint or in the palm, the nodule can get snagged in the sheath and lock the finger.  Forcing it open can cause more tearing and the build up of even more scar tissue.  A downward spiral begins;  Hark, what discord follows.  As I felt Amy's hand, I could feel the little nodule bumps of scar tissue gliding back and forth. 

Have you ever heard about the legend of the Gordian Knot?  It was a knot so complicated that it was impossible to solve or unravel.  Thousands tried but none were successful until Alexander the Great attempted to untie the knot. When he could not find the end to the knot to unbind it, he sliced it in half with a stroke of his sword.  This technique of problem solving was called the "Alexandrian solution."  A technique many doctors use today. 

If Amy were to go see a doctor, the first thing he may suggest is to stop playing the piano for weeks or months, rest and wear a brace.  Rest in these situations is not going to help.  The body's defense against this kind of damage is to create scar tissue which is not flexible and will lock the tissue in place much like a spider web can entomb and insect.  Scar tissue is what caused her problem in the first place.  If you were to take an unraveled rope and just throw it in a pile, it would be in a tangled mess of a knot.  Letting it sit there for six months will not untangle it.  You need to slowly and patiently unravel it and straighten it out and then roll it back up neatly.  That is what our bodies want us to do.  When it comes to scar tissue, proper movement promotes healing, not rest.

A second treatment a doctor may prescribe Amy is physical therapy.  This is close to the solution because as I said, proper movement promotes healing but PT most likely will not solve her problem.  She will receive massage therapy, contrast baths, working with weights and pulleys, molding clay, wax and other muscle building techniques, but, when Amy goes home to her piano, all the physical therapy in the world won't be able to counteract the damage she will do in the privacy of her own home or practice room.  Like the Battle of Thermopylae, it doesn't matter how many Persians march through the pass, the Greeks had the upper hand.

A third treatment option will most likely be a cortisone shot.  Cortisone melts tissue.  If the doctor can inject the cortisone directly into the nodule he can melt it away, along with anything else which comes in contact with the cortisone.  No thank you.

A final treatment will be surgery where they will cut the sheath or scrape the nodule off the tendon and of course, the body will respond to the surgery by creating - say it with me - "scar tissue."  The good news is during the several months it takes to fully heal, with PT, you will have full control over your fingers again.  This may be a solution for the average person, however, for a concert pianist, the result could be devastating. 

So what was Amy's problem causing her symptoms?  It was simply her flat finger technique.  Now, I'm not a university piano professor so I don't want to comment on his desire for Amy to play with flat fingers.  What I do know is that the finger is made up of several bones which neatly line up and are held together by ligaments, pulled by tendons and controlled by muscle.  If I were to poke you in the eye, I would align my fingers so all the bones were in a straight line for maximum eye poking jabs.  A curved finger would not do the job as effectively.  When playing the piano, the opposite is true. 

There are two ways I teach my students to find their optimal finger alignment or kinetic chain.  The first is to lay on the floor, flat on their backs with bended knee.  With their arm to their side, gently isolate one finger and lightly press it to the floor while lifting the whole arm off the floor.  Then gently rotate, swivel and explore a circle with the finger touching one spot on the floor.  Not to get all Zen here, but as in everything in life, it is in the imbalance where we can find the balance.  If you shift too far forward you will feel the tension in the front joint of the finger, too far back you will feel the tension in the tendon beneath.  If you hyper-extend the finger, you will experience that discomfort, too.  Do this will all five fingers and upon discovering the perfect effortless alignment, look at the finger and palm and take note of the perfect curve much like the dome of a cathedral ceiling.  That is the finger at its optimal strength where the load bearing bones are properly aligned by the tendons.   A second method of finding this alignment is to stand with your arms to your side.  Shake your hands until they are loose then let them hang to your side. Without moving a single finger, raise your hand and look at your fingers and palm.  They should be in perfect alignment for optimal piano playing power. 

It is the bones that depress a key and it is the tendon which puts the bone in place to play it.  Amy's flat finger technique was forcing the tendons to play the key and as a result was fraying her tendons and ligaments like a nylon rope.   I'll repeat, it is the tendon which aligns the bone and the bone which presses the key down through the use of gravity and the weight of the arm.  Tendons are for alignment, ligaments hold the bones together, bones do the load bearing work.  Deviate from nature's design and you're going to have problems.  These ligament, bone, muscle and tendon duties are not interchangeable.  Can we do it?  Sure.  Should we?  I can rob banks and make a lot of money but eventually I'll get caught and arrested.

After only two months of study with me, Amy's symptoms have pretty much disappeared and she stopped taking lessons. That is really unfortunate for her as she has several other problems her university piano professor has not addressed.  She also has a pretty bad ulnar deviation of the wrist and she has adduction and abduction issues with her thumb.  The combination of these two movements will eventually strain the tendon in her thumb creating a leakage of synovium fluid, the lubricant within the tendon sheath, and create a ganglion cyst or, "Bible Bump."  Guess how Dr. Alexander will treat this? 

-Malcolm Kogut (not a doctor, either).