Whilst the main subject of this article focuses on musicians, the same principles apply across a wide range of RSI cases. So even if you are not a violinist or pianist, but just simply can't work at your computer or even write with a pen any more, read on if you want to 'look under the bonnet'.

All music involves the hands except for voice. Even the humble harmonica uses the hands to side shift the instrument. The hands and forearms are my area of particular expertise. Over 28 years of experience with student musician’s problems I have seen a great variety of problems which both directly and indirectly affect high-level performance. Conditions arising from trauma such as sprains and fractures are common. Carpal bone displacements and adhesions with consequent tendinous irritations are often observed in such cases. Technique habits which may have persisted since childhood which were once useful but are now superfluous, can continue to predicate style and production. 

Working with many seasoned professionals has also extended my experience. With each new patient comes a new variation of signs and symptoms, each one an education in itself. 

I too have suffered many wrist injuries as a result of the hands-on work that I do. Intense guitar playing and ‘mousing’ my PC for hours creating websites don’t help either. However, such episodes have served to edify me with regard to the general and specific nature of finger, wrist, arm, shoulder, neck and upper ribcage interactions. Said interactions manifest via lines of tension, nerve pain, pins and needles, muscle ache and joint ache by virtue of a sequence of shortening of adjacent structures in response to habit and irritation. 

I have found that the majority of  symptoms arise from the deep muscles, hwever, often the tendons of the superficial muscles are irritated as they pass over areas where the carpal bones are misaligned and or inflammed.

When the deep ‘stabilising’ muscles of the forearm become hypertonic or overly tense they lose Oxygen and rapidly tire, causing pain. This reaction in the deep muscles is more likely than with  the superficial layers due to the type of reflex tone setting mechanism and because of restriction to their expansion. The girth of the deep muscles is more tightly constrained than the superficial muscles. This physical constraint to expansion is due to the membranous sheath which envelopes every skeletal muscle of the body. Described as a stout membrane, the epimysium is a layer of connective tissue which ensheaths the entire muscle. It is composed of dense connective tissue and is continuous with the fascia of adjacent muscles and the internal connective tissue wrappings within the muscles.

Click to see detailed anatomy of the forearm and hand.

The density of this sheath varies from deep to superficial muscle layers. Thus, when the deep muscles expand through constant and also unique occasions of overuse they become constrained by the limits of the dense membranes enveloping them. When this state of hypertonus has persisted for some time the nervous system registers the increased tone as normal and automatically maintains the tension even though it is no longer appropriate. Pain will be generally perceived at the anchor points of the muscles and their tendons i.e. the elbow and upper forearm, and the fingers and wrist.

Often I have observed that the superficial layer is weak and flaccid whilst the deep layers are very dense and shortened. Observation of  top professional pianists demonstrates that the relaxed, flowing approach to playing, honed by many years of skill acquisition and the relative absence of  poor postural and technique habits plus familiarity with their own repertoire serves to maximise their performance abilities. However, even these performers can be struck down by injuries such as falls on to the hand, gardening, decorating, writing, carrying heavy bags, and a host of other trauma.

I am able, by virtue of  specialised and unique hands-on techniques that I call ‘Myo-articulation’, to reverse deep tension patterns quite swiftly. If there is carpal bone derangement present, I can very specifically locate and ‘undo’ adhesions and re-align these delicate little bones of the wrist. I will ‘track’ the tension patterns along the arm and identify shoulder, ribcage and neck involvement. These I will then release using a variety of techniques such as articulation, massage and manipulation where necessary.

It is even possible to identify, by palpating the tensions in individual muscles, specific playing related patterns of overuse such as the little finger in trills on the violin, over- gripping and over-flexing in the bowing hand and much more. 

Working with the students has often involved dialogue with their tutors. This has enabled me to get objective feedback about ‘cases’ thus further enhancing my development in this area. 

I hope that this short article has helped you to undersand more about this, all too often mysterious condition.

Paul Manley 2008