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).
