The Clarinetist’s Enemy: Tendinitis: Part 2
By Rebecca Rischin
Professor of Clarinet and Woodwind Division Chair
Ohio University
In the previous blog, we discussed how begin vigilant of your daily activities can prevent tendinitis from occurring. This blog will discuss treatment.
What to do when one is in pain? First, do not panic! The most important thing to do for the treatment of tendinitis is to see an orthopedist for an expert diagnosis and to rest the afflicted area as much as possible. If resting completely is not an option, then it is important to 1) reduce the duration of practice and to alternate practicing slow passages with fast ones; and/or 2) schedule breaks approximately every 20 minutes in which you are not using your hands and arms. However, if one can afford to take time off, rest is the best medicine. Remember that rest means not only time off from playing the clarinet, but time off from doing other activities that can cause or aggravate tendinitis, such as using a computer, tablet or phone, cooking, carrying heavy items, and other activities discussed in part one of this blog.
An orthopedist or general practitioner can prescribe physical therapy which may include massage, ultrasound, magnet therapy, a warm paraffin wax soak, and strengthening/stretching exercises. Acupuncture or acupressure may also help. Icing the forearm with an ice pack or a bag of frozen vegetables is essential, as icing reduces inflammation. Voltaren is a non-steroidal anti-inflammatory topical gel most often used for arthritis but also beneficial for tendinitis. It now comes over the counter in a cheaper generic form called Diclofenac. Bio freeze, Icy hot or similar ointments can also soothe the pain, as can oral non-steroidal anti-inflammatory medications. However, be sure to consult with your doctor about anti-inflammatory medication as excessive use can cause other health problems.
Practicing with cold hands can be detrimental, as the tiny muscles and tendons in the fingers and forearms need blood in order to function. Just as dancers wear legwarmers when they are rehearsing, clarinetists can wear fingerless gloves to keep their hands warm. Simply cutting off the tips of cheap wall gloves will work, but fingerless gloves are also available online. Running the arms and hands under warm water before practicing is a must.
Stretching the arms and hands is also essential before and after practice. A runner would not think of running a race without first stretching the legs and yet it is amazing how much musicians take their bodies for granted! Regular cardiovascular exercise for overall health is also essential, but remember to avoid cardiovascular exercise that uses your arms, as was stated in part one.
Weak muscles are more prone to injury. It is important to maintain a strong upper body via regularly lifting weights and doing strengthening exercises using a hand exerciser and putty. Be sure that you strengthen your shoulders in addition to your arms. However, it is important to let the muscles and tendons fully recover from tendinitis before you begin a strengthening program as doing so too soon can exacerbate the problem; and to be careful not to lift weights that are too heavy so as prevent further injury.
For a severe case of tendinitis resistant to physical therapy, a cortisone shot, a steroid injection that reduces inflammation, is an option. But while cortisone can offer immediate relief, it is not a long-term solution because repeated use may weaken the tendon and in severe cases cause the tendon to rupture, requiring surgery. In addition, repeated use of cortisone may lessen efficacy such that the shot only lasts a few months. If seeking a cortisone injection, be sure you see an experienced orthopedist who has administered many such shots before, as it is essential to find just the right spot for the injection.
A healthier alternative to cortisone for severe tendinitis is PRP injections, “platelet rich plasma” injections, in which the individual’s blood is taken, put in a medical machine to separate the platelets, and then re-injected into the individual, thus stimulating the body’s natural healing process. However, PRP injections must be done by a trained specialist and are unfortunately not covered by insurance. They can cost up to $500 each! They also involve a longer recovery time then cortisone. The advantage is that they do not weaken the tendons and they tend to last longer than cortisone, between six and nine months.
Some say that a gluten-free diet can be beneficial, since gluten is an inflammatory agent, but it may be very difficult to say goodbye to bread, cake, cookies and pasta! However, numerous books and articles have extolled the role that nutrition plays in the health of our muscles and tendons. Taking a multi-vitamin, especially Vitamin D and Co-Enzyme Q-10, and maintaining a healthy blood level of TSH (the hormone secreted by the thyroid gland) are also recommended for optimal muscle and tendon health.
Once one has analyzed one’s daily activities and determined that the problem is not simply overuse, it may be helpful to assess one’s playing technique via Alexander Technique or Feldenkrais lessons, which increase awareness of posture and bodily motion and can locate sources of tension. Yoga can also help, as can practicing in front of a mirror or video recording yourself to analyze hand position and excess motion. If right arm pain is the problem, an ergonomic thumb rest such as those by Kooiman or a neck strap that attaches to the thumb rest can be a godsend! An instrument repair technician can also replace your standard thumb rest with one with a hook so that you can use a sturdier neck strap designed for the heavier saxophone.
In sum, do not despair! Take heart in the fact that you are not alone! Everyone from secretaries to tennis players, violinists to professional chefs has occasionally experienced tendinitis. The bad news is that it is painful and worrisome. The good news is that it is not a permanent condition. Rest and medical treatment will help you get through it and modifying your everyday activities and lifestyle will make you healthier and happier forever.
