“I’m Just In the Band”

Patient Presentation
A 13-year-old female came to clinic for her health supervision visit. She had no concerns except for a dry red rash on her chin. She said that she had it off and on but it had worsened in the past two weeks. She denied any new soaps, lotions, or cosmetics. The past medical history was non-contributory. The social history showed that she was doing well academically in 8th grade. She played the clarinet and was in a church-organization that performed community service.

The pertinent physical exam revealed a healthy female with growth parameters in the 10-25%. Her skin examination showed some dry irritated skin about 2 cm wide that extended linerally from her lip to her chin. It did not appear infected. Her left index finger and right thumb also showed some irritated skin. She denied any changes in skin sensation or pain.

The diagnosis of a healthy female with dermatitis was made. The physician asked more questions about her skin and the girl offered that she had been practicing her clarinet more because of some upcoming performances plus a high-stakes audition. She also offered that her hands and shoulders had been hurting her somewhat for the past two weeks since she had significantly increased her practice time. She denied any lip-licking or changing any equipment including her clarinet reeds. The physician explained that although she understood the need to practice more that the girl was overdoing it. “We can deal with rash on your chin from all the saliva, but you are rubbing your fingers on your clarinet and your hands and shoulders are sore. You might be able to do well in the audition, but how are you going to play after that?” she asked. She continued, “You are a performer just like any other well-trained athlete, and…” “But I’m just in the band,” the girl interrupted. “You are an athlete just like any other athlete who has to practice to perform their best. If an athlete suddenly increases their training, they often can get hurt. You need to increase your training or practicing just like an athlete does for your performances and audition. You have to work up to it and take care of your body,” the pediatrician advised. The mother didn’t know about the hand and shoulder pain and agreed that this needed to be addressed and they would talk with the music teacher. The pediatrician recommended to split her practices into two times a day for shorter amounts of time, and to change positions often between sitting and standing. She also recommended if possible using a mirror to check her positioning from time to time while practicing. “Athletes don’t do the same thing all the time and you shouldn’t too. Your music teacher probably will have other suggestions for positioning and increasing your practice time in a smart way.” In the meantime, the pediatrician recommended using emollients on her chin and hands to help with the dermatitis, and not holding her clarinet so tightly.

Instrumental music, either as an avocation or profession, provides great pleasure for those performing and listening. Unfortunately it can also cause health problems. Many of the problems are musculoskeletal or neurological in etiology due to overuse and the musician may experience pain. Prelude to pain can include stiffness or tingling or other skin sensations. Musicians may experience weakness, loss of function, control (accuracy) and ability (speed) as well as problems with tone.

“The most prevent problems involve overuse of muscles resulting from repetitive movements of playing, often in combination with prolonged weight bearing in an awkward positions.” String players have the highest prevalence of musculoskeletal problems. Musculoskeletal strain can also be caused by transporting large or awkward instruments and equipment inappropriately. Other common health problems of instrumental musicians include peripheral neuropathies, dermatitis and other otolaryngological problems.

In prevalence studies of school-age children (7-17 years) learning and performing instrumental music, 67% reported at least one time during their lifetime an instrument-related musculoskeletal problem, 56% had an experience in the past month, and 30% reported being unable to play their instrument at least once because of the problem. Of those reporting a problem, within the past month, 5% had taken medication for the problem and 4% had sought medical attention for the issue. Females and musicians who were older reported more problems. Older musicians and those playing more instruments have increased risks of problems because of the increased exposure and use.

Musicians young and old need to be taught proper technique and reminded of proper technique to mitigate potential problems. Musicians need conditioning to strengthen the primary and secondary body areas for the instruments and to acclimate the performer to the performance levels needed. This is the same as any other well-trained athlete or performer.

The main treatment for musculoskeletal problems is rest. Other options include analgesics and anti-inflammatory medications, muscle relaxants, acupuncture, physical therapy including heat/cold, ultrasound, and electrical stimulation treatment. Also rehabilitation therapies including splinting, stretching and stabilization of various musculature, and surgeries (nerve entrapment or compression, muscular incompetence may be needed. Psychological, dermatological, dental, audiology and speech therapy professionals may also offer other help for musicians.

Learning Point
Health problems due to instrumental music performance include:

  • Musculoskeletal
    • Strain
    • Tenosynovitis
    • Musculature incompetence due to overuse and pressure – examples include due to velopharyngeal muscles, orbicular oris muscle or “Satchmo mouth” named for trumpeter Louis Armstrong, or oral muscular incompetence or “Gillespie Cheeks” named for trumpeter Dizzy Gillespie.
    • Hypermobility syndrome
    • Arthritis
    • Joint nodes – Heberden’s and Bouchard’s
    • Temporomandibular joint pain – especially in upper string and brass players
  • Neurological
    • Compressive neuropathies
    • Nerve entrapments
    • Focal dystonia – involuntary, localized motor movement that interferes with the playing ability
    • Sensory loss to specific areas of pressure
    • Visual field loss – due to high intraoral pressures in woodwind and brass musicians
    • Neuromas
  • Dermatological
    • Dermatitis – acute or chronic, due to contact of various parts of the body with the instrument or other substances. Improperly fitted instruments, friction and hygiene also add to the problem. Fiddler’s neck, cellist’s chest, flautists’s chin, guitar nipple are all examples of dermatitis.
    • Allergens – “The most frequently reported culprit substances were: colophony [rosin], exotic woods, nickel sulphate, varnishes, and propolis (bee glue).”
    • Calluses
    • Subungual hematomas and onycholysis
  • Otolaryngological
    • Hearing loss
    • Laryngocoele – due to increased air pressure
  • Dental
    • Increased tooth calculus – especially in single reed instrumentalists
    • Bruxism – especially in brass players
    • Malocclusion – i.e. cross-bite in violinists
  • Infectious Disease
    • Herpes simplex infections
    • Impetigo
  • Psychological
    • General stress
    • Performance anxiety
  • Cardiac
    • Unmasking of underlying cardiac anomalies such as patent foramen ovale due to valsalva maneuvers
    • Potential arrhythmias such as AV block

Questions for Further Discussion
1. What are some health problems in other performing arts such as dance or vocal music?
2. What health related problems are seen in the visual arts?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: http://www.nlm.nih.gov/medlineplus/rashes.html, http://www.nlm.nih.gov/medlineplus/ergonomics.html, http://www.nlm.nih.gov/medlineplus/sportsfitness.html and http://www.nlm.nih.gov/medlineplus/exerciseandphysicalfitness.html.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Liu S, Hayden GF. Maladies in musicians. South Med J. 2002 Jul;95(7):727-34.

Lombardi C, Bottello M, Caruso A, Gargioni S, Passalacqua G. Allergy and skin diseases in musicians. Eur Ann Allergy Clin Immunol. 2003 Feb;35(2):52-5.

Ranelli S, Straker L, Smith A. Prevalence of playing-related musculoekeltal symptoms and disorders in children learning instrumental music. Med Probl Perform Arts. 2008;23:178-185.

Ranelli S, Straker L, Smith A. Playing-related musculoskeletal problems in children learning instrumental music: the association between problem location and gender, age, and music exposure factors. Med Probl Perform Art. 2011 Sep;26(3):123-39.

Rodriguez-Lozano FJ, Saez-Yuguero MR, Bermejo-Fenoll A. Orofacial problems in musicians: a review of the literature. Med Probl Perform Art. 2011 Sep;26(3):150-6.

Lee HS, Park HY, Yoon JO, Kim JS, Chun JM, Aminata IW, Cho WJ, Jeon IH. Musicians’ medicine: musculoskeletal problems in string players. Clin Orthop Surg. 2013 Sep;5(3):155-60.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital