(c) 2004 by Dr. Timothy Jameson
Doctor of Chiropractic
Castro Valley, CA

A common problem among both acoustic and electric guitar players, as well as other stringed instrument players, is the development of forearm pain, tingling, and numbness, typically on the same side that you fret the instrument.  This column will explain a specific type of repetitive injury called cubital tunnel syndrome, which affects the inner side of the forearm and the pinky side of the hand. Most musicians are probably not familiar with this syndrome even though the symptoms are experienced by many.  The typical presentation of the syndrome, the anatomical structures involved, along with prevention and treatment options will be discussed in this article.

Cubital Tunnel Syndrome typically involves pain and/or abnormal sensations in the elbow area, along the inner side of the forearm. The pain can travel downwards towards the pinky, and can be accompanied by tingling or numbness sensations to the pinky side of the hand. The forearm muscles can be achy, sore and painful, and can lead to a misdiagnosis of tendonitis by an inexperienced doctor.

This syndrome usually only involves the ring and pinky fingers, since these fingers receive their nerve supply from the ulnar nerve. Some variations in the nerve supply to the fingers may allow for the middle finger to be involved as well. The ulnar nerve begins from nerve fibers exiting from the spine in the neck, called the cervical spine.  The nerve traverses down the arm, passing through the "funny bone" area of the elbow, then travels down the outer side of the forearm to hand muscles along with the 4th, and 5th fingers. The purpose of the nerve is to allow for communication between the brain and hand, allowing for both motor control of the hand, and sending sensation from the hand to the brain.

If the syndrome progresses, it can lead to decreased function of the hand, especially grip strength. It is common also to experience tingling and numbness in the fourth and fifth fingers. Wasting or atrophy of the pad of muscles on the palm side below the pinky finger can develop as well. Typically, the person notices that flexing the forearm tends to irritate the symptoms. Another symptom is the musician beginning to notice that he/she cannot control the fourth and fifth fingers very well.  It's as if they're trying to control finger motion, but the hand just is not receiving the signals and has a “mind of its own.”  Loss of dexterity, speed, and control of the ring and pinky fingers is a hallmark sign of this syndrome.

The culprit in this syndrome is compression of the ulnar nerve. Just south of the elbow, the nerve passes through the flexor carpi ulnaris muscle to travel down to the hand. A small tunnel forms in this location, and the nerve becomes surrounded on all sides. In this tunnel, the ulnar nerve sits on top of the flexor digitorum profundus muscle. A ligament forms the top layer of the tunnel. It is important to understand the function of the muscles in this tunnel, because they play a major role in the development of the syndrome. The flexor carpi ulnaris muscle attaches to the inner part of the elbow, and its function is to flex the wrist and move the wrist inward towards the pinky. The flexor digitorum profundus attaches to the medial elbow and inserts into the tips of the fingers. This muscle's function is to flex the fingers (especially the tips).

Now that you've survived the anatomy lesson, let's discuss in real life how these anatomical structures are affected with guitar playing. As I stated earlier, this syndrome typically affects guitarists in the fretting hand, so in a right handed guitarist, the left hand is typically involved. If we dissect the playing of a simple barre chord, we would notice 1) contraction of the thumb against the underside of the neck of the guitar, 2) a counterbalancing contraction of the opposing fingers on the top fretted side of the neck, 3) bending of the fingertips to push against the strings, 4) flattening of one finger against the neck to form the bar (usually the first finger), 4) maybe some stretching of the pinky to reach a higher fret and 5) flexion of the wrist.

Since the ulnar nerve passes between the muscles that perform flexion of the wrist, bending of the fingertips and stretching the pinky to reach the higher frets can irritate the muscles surrounding this nerve. With constant overuse of these muscles, they can become inflammed, or actually form "microtears" at the attachments to the elbow. This is especially evident in guitarists who have not developed strength in their forearm musculature in preparation of hours of practice time.  The swelling involved can start squeezing down on the ulnar nerve, causing the symptoms mentioned above. This is also why bending the forearm will worsen the complaints. The ulnar nerve becomes stretched upon flexion of the elbow. If the nerve already is being pinched, the stretching is going to amplify the symptoms.

Cubital tunnel syndrome can also occur from other maladies, such as traumatic injuries to the elbow from car accidents, falls, elbow fractures, and elbow dislocations.  Many musicians also do computer work on the side, and repeated keyboarding at the computer with poor posture and little rest time, and constantly leaning on their elbows while at the computer can predispose the musician to ulnar nerve problems. Overall poor health of the musician is a complicating factor as well.  Not exercising, poor nutritional intake, alcohol and drug consumption, and preexisting health conditions can weaken the body to make is more susceptible to neurological insult. 

A very important cause of CTS that must not be overlooked is neck problems.  Since the nerve fibers that travel to the hand must first exit the spine, any problems with the cervical spine in that vicinity will irritate the nerves.  For example, if you have suffered a whiplash injury from a car accident – even years previously – it can predispose you to cubital tunnel syndrome.  Chronically bad posture and forward head tilt can also lead to nerve compression. Consider your posture while playing your musical instrument.  How many guitarists do you see in a forward head posture, leaning over the axe, while playing difficult passages? How about shredders who are flailing their heads back and forth while playing their high-speed arpeggios? Chronic poor posture exerts tremendous strain not just on the neck, but upon the entire spine and nervous system.  Unfortunately in a majority of cases, you will never experience actual discomfort in the neck with cubital tunnel syndrome.  It’s important to note that only a Doctor of Chiropractic can determine if the neck is the source of your problem.  Physical therapists and medical doctors do not receive training in locating and correcting spinal subluxations – the misalignments that irritate and distort nerve function.

For those of you who do not have the symptoms mentioned and would like to prevent them from ever occurring, there are a few simple steps to take:

1) Give yourself more frequent breaks (about a 10 minute break after every 45 minutes of playing) during rehearsing or practice times. The constant playing for hours upon hours without resting can lead to microtearing of the muscles and the resulting repetitive strain.

2) Before you play and during your breaks, increase blood flow to the forearm and hands by stretching and performing self-massage to the area. (You may want to visit your library or bookstore and look into some massage techniques - these help to increase the blood flow to your arms and flush out toxins.)

3) Begin receiving regular massages by a professional massage therapist to keep your muscles supple and relaxed.

4) Have an evaluation by a doctor of chiropractic to make sure the alignment of your neck, shoulders, and elbows is correct, allowing proper nerve flow to the muscles of your hands.

5) Enhance your nutrition and use nutritional supplements so your body has all the building blocks need to cellular repair and nerve transmission. 

6) Begin and/or maintain a weight training regimen that concentrates not only on the major muscle groups, but the forearm and hand muscles as well.  The stronger those muscles are, the less chance of fatigue and injury.

If you do have the symptoms mentioned in this article:

1) If you simply have some forearm muscle soreness, use heat on the forearm before practicing, and ice the elbow and forearm area after playing. The heat will encourage more blood to the tissues while playing, and the ice will discourage swelling afterwards. Perform stretching to the forearm three to four times daily.

2) If you are experiencing nerve related symptoms like tingling and numbness, burning sensations, muscle fatigue, and lack of coordination of the fingers, see a Doctor of Chiropractic immediately who is experienced in treating musician's injuries. Many musicians make the mistake of seeing their general medical practitioner who is not trained in caring for repetitive strain injuries. Most musicians who go the medical route receive dangerous medications that may actually worsen your condition. Even something as simple as ibuprofen can damage the kidneys and liver.  With this in mind, do not become an anti-inflammatory junkie.  Repeated use of antiinflammatories will simply mask a more serious underlying problem, and can lead to organ problems.

3) Always try conservative measures first, such as chiropractic, massage therapy, or acupuncture. Give yourself at least six to eight weeks to heal.

4) If you notice symptoms worsening, or weakness occurring in the hands, even with the conservative care programs provided to you with chiropractic and massage, your health care provider should refer you to a neurologist for a consultation and neurological testing. In my experience in working with musicians via chiropractic care, this rarely happens.  I would estimate 90% of patients who present to my office with these symptoms overcome them with natural, conservative chiropractic wellness care, and become healthier, more creative musicians in the long run.

Finally, don’t “hope the problem with go away.” If you are a guitarist or musician of any instrument, and begin noticing changes in the function of your hands, do not wait to have them evaluated.  The faster you receive care for them, the faster they will heal.  Musicians who put off receiving treatment for cubital tunnel syndrome risk the more serious consequences of hand muscle wasting, numbness, loss of ability to play their instrument, and chronic disability.  Treat your body as a temple, and care for it daily.