Musculoskeletal injuries and tendinopathies are common in musicians and tend to present in the same way that they would in nonmusicians. Meanwhile, neurologic injuries are vastly more prevalent than in nonmusical populations, making focal neuropathies, cervical radiculopathy, thoracic outlet syndrome, ulnar neuropathy, carpal tunnel syndrome, overuse syndrome, and focal motor dystonia important diagnoses to recognize and maintain in your differential diagnosis.

In what has been called the “trumpet player’s neuropathy,” focal neuropathies of the neurovascular supply to the lip have been identified, primarily in brass and woodwind players (8). Playing woodwinds with leaky valves or pads increases the effort required to produce a note and may be a risk factor for this injury type (4).

Due to the leftward rotation and lateral flexion of the neck required to cradle the instrument, cervical radiculopathy is common in string musicians. This posture causes loading of the facet joints and anatomic narrowing of the ipsilateral neural foramen. Upon physical examination, one should perform a Spurling test (also known as the quadrant test)
where downward pressure is placed on the top of the rotated and extended head. A positive test is defined by pain and paresthesias spreading distally in the distribution of a cervical nerve root on the side that the patient is facing. Multiple studies have shown the Spurling test to be a reliable diagnostic tool with specificities ranging from 92% to 100%. Although with sensitivities of only 28%-60%, it should not be used for screening purposes (10). Consequently, even without suggestive exam findings, a magnetic resonance imaging (MRI) or electromyography (EMG) must be pursued if clinical suspicion is high.

Thoracic outlet syndrome results from compression of the neurovascular structures passing through the superior thoracic outlet. The brachial plexus, subclavian artery, and subclavian vein are all at risk of compression while passing between the anterior and middle scalene muscles. Compression may be functional, due to shifts of the clavicle in relation to the shoulder girdle during performance, or static, as in the case of those with a cervical rib. Symptoms typically begin as vague paresthesias and pain located in the medial forearm and hand (C7, C8, or T1 dermatomes). Multiple exam maneuvers have been developed to identify the condition, but retrospective studies have found that Adson’s test, Wright’s hyperabduction test, Roos test, and the costoclavicular maneuver all have high false-positive rates (10). Therefore, clinical diagnosis must be made with a thorough history guiding a focused radiographic exam. The treatments of choice are postural training and physical therapy. However, when conservative methods fail, surgical decompression is sometimes required.

With the elbow maintained in a constant state of flexion during prolonged periods of play, ulnar neuropathy at the elbow is a common injury resulting from the strain of supporting a string instrument. Diagnosis is suspected based on history and can be confirmed if a Tinel sign is present at the cubital tunnel. Conservative management with nonsteroidal anti-inflammatory drugs (NSAIDs), avoidance of aggravating activities, and splinting typically leads to resolution of symptoms within weeks.

Often seen in pianists, carpal tunnel syndrome can result from repetitive flexion and extension of the wrist. The condition can also develop in the bow or pick hand of string instrumentalists and is common in keyboardists as well. Typical symptoms include numbness, tingling, pain, and, in severe cases, weakness of the lateral three and a half fingers, which are supplied by the median nerve. The Phalen test is a good screening exam with poor specificity reported but a sensitivity of about 80%. Meanwhile, a positive Tinel sign at or just distal to the carpal tunnel is virtually diagnostic with specificities approaching 100%, but it should not be used for screening due to poor sensitivity (11). Treatment options include avoiding provocative activities, night splinting, NSAIDs, steroid injections, and surgical release if conservative management fails.