Rheumatic and musculoskeletal disorders in musicians: risks, adaptations and management

Abstract

Music therapy is recognised as a complementary or alternative therapy for osteoarthritis and fibromyalgia, but playing music can have health repercussions for musicians in the field of rheumatology.

Limited articles exist on artists developing rheumatic diseases before 1900, possibly due to underestimation, poor understanding or a lack of awareness. Conditions like Marfan syndrome may confer hypermobility-enhancing virtuosity, as seen in Paganini and Rachmaninov.

Among contemporary musicians, Edith Piaf, Lady Gaga, Selena Gomez and Céline Dion suffered from rheumatic diseases, and it was true obstacles for their careers.

Repetitive movements, inadequate posture and instrument-specific physical demands contribute to musculoskeletal disorders in musicians, particularly tendinopathies and entrapment syndromes affecting the upper limbs. These conditions result in chronic pain, reduced mobility and performance decline. String and wind instrument players face heightened vulnerability due to the unique constraints of their instruments.

Given the longevity of musical careers compared with athletic ones, specialised medical management and targeted prevention strategies are crucial. Minimising the impact of these conditions is paramount to ensuring musicians can maintain optimal performance and extend their careers under the best possible conditions, enabling a preventive approach, follow-up and specialised care for as long as needed. Therefore, further exploration of rheumatic diseases in musicians is warranted, particularly with an emphasis on the evolution of medical knowledge and clinical practices. These pathologies are complex and require specific treatment. Some European health professionals and musicians are training in the practice of ‘arts medicine’.

Throughout history, music has consistently held a significant place in society. Its impact on human health and disease is illustrated in a Western manuscript from 1472, which depicts a fragment of Galen’s Four Humors as well as in a scene from a late-medieval Herbal.¹ The World Federation of Music Therapy defines music therapy as the utilisation of music and its elements to address the physical, emotional, cognitive and social needs of individuals affected by conditions such as depression, anxiety, stress, dementia, cancer and pain, among others.² Although supported by a weak level of evidence, music therapy is recognised as a complementary or alternative therapy for osteoarthritis³ and fibromyalgia.⁴ In a randomised clinical trial involving patients with chronic rheumatic diseases (eg, osteoarthritis, low back pain or cervicalgia), listening to music during medical consultation was associated with lower anxiety levels and heart rate compared with patients who were consulted without music.²

While enjoyable to listen to, does playing music also have health repercussions for musicians in the field of rheumatology?

Pre-existing disease led to music practice

Some diseases can be an advantage to music practice,⁵ as seen with Niccolò Paganini and Sergei Rachmaninoff,⁶ both Italian violinist and Russian pianist respectively, who had Marfan syndrome. This syndrome,⁷ a potentially life-threatening autosomal dominant genetic disease caused by a connective tissue disorder impacting cardiovascular function, granted them hypermobility. This enabled them to become virtuosos, exploiting the extreme flexibility of their fingers.^{8 9}

Niccolò Paganini (1782–1840), the renowned Italian violinist widely regarded as one of the greatest virtuosos of all time, was born in the Republic of Genoa in 1782. He began learning the mandolin at the age of 5, took up the violin at 7 and by the age of 28 had achieved fame across Europe.¹⁰ He was known for his remarkable memory and extraordinary technique, facilitated by his peculiar mobility and the shape of his left hand, nicknamed ‘a diabolical left hand’, explaining that even young virtuosos cannot play as Paganini. He could extend his fingers across the entire violin at distances unreachable by other virtuosos. Cartoonists often depicted him with an oversized left hand and slender figure. Described as having suppleness without muscles or bones, his hand sparked accusations of using a smaller violin, which he repeatedly disproved. While his Marfan syndrome diagnosis remains debated, with some suspecting Ehlers-Danlos syndrome due to his lack of arachnodactyly, he also suffered from dysphonia. Though tuberculosis and syphilis were proposed hypotheses, recent studies suggest Marfan syndrome as the cause because cardiovascular complications, particularly aortic arch involvement, may have compressed the recurrent laryngeal nerve, causing his dysphonia.^{8 9} Later in life, he developed additional complications, including oesophageal stricture, rectal stenosis, urethral narrowing and palate ulceration, which led to the hypothesis of iatrogenic mercury poisoning.¹⁰

Sergei Rachmaninoff (1873–1943), the renowned Russian virtuoso pianist and composer, was born into a family said to be descended from the Moldavian prince Stephen the Great. He began piano lessons at the age of 4 and soon demonstrated exceptional talent.^{5 10} He was renowned for his exceptional piano concertos. His fingers exhibited extreme flexibility, often compared with an octopus, enabling him to stretch across an octave and a half—a characteristic of arachnodactyly. One possibility would have been Marfan’s syndrome, but his limbs were not elongated and he had no other manifestations of that condition such as scoliosis, pectus excavatum and eye or cardiac complications.¹¹ Acromegaly is an alternative diagnosis. He also suffered from myopia and debilitating headaches, which forced him to stop playing for 3 years in 1917. In addition, he experienced severe back pain, fatigue, hand stiffness, arthritis and a persistent cough. He died in 1943 from an aggressive form of melanoma.¹¹

Despite their illness, these musicians were true virtuosos, whose exceptional hypermobility provided a unique advantage. However, they could not escape the complications that impacted their quality of life and musical careers.

To sum up, hypermobility can affect all musicians, potentially benefiting finger dexterity and enabling exceptional reach in piano playing. However, it can also be a disadvantage when it affects supportive joints such as the back and knees, compromising stability.⁸ Scoliosis, characterised by spinal torsion, is often pre-existing but asymptomatic, becoming apparent through musical practice. Certain playing postures can lead the body to compensate, potentially triggering pain.^{12 13}

Rheumatic diseases can appear independently of musical practice

Limited articles exist on artists developing rheumatic diseases before 1900, possibly due to underestimation, poor understanding or a lack of awareness. Among contemporary musicians, Edith Piaf,¹⁴ Lady Gaga,¹⁵ Selena Gomez¹⁶ and Céline Dion¹⁷ suffered from rheumatic diseases, and it was true obstacles for their careers. Edith Piaf, a French singer, had rheumatoid arthritis treated with steroids, but also used opioids, sleeping pills and alcohol, leading to liver cirrhosis.¹⁴ Lady Gaga¹⁵ revealed in 2017 that she suffers from fibromyalgia, leading to tour cancellation during her music career. Selena Gomez, suffering from systemic lupus erythematosus, underwent a kidney transplant and temporarily withdrew from music.¹⁶ Celine Dion, diagnosed with stiff-person syndrome, has been unable to sing, forcing her to cancel concerts.¹⁷ These highly publicised cases have raised awareness, with Google Trends data showing increased searches related to these illnesses after public announcements.

Michel Petrucciani (1962–1999), a French jazz pianist with osteogenesis imperfecta, a congenital disease causing bone fragility and growth deficiency, led to reduced bone mineral density and cortical thinning, faced significant constraints. As an adult, he was 90 cm tall and weighed 23 kg. However, his fingers were unaffected, remaining long and well-suited for piano. He adapted his practice, requiring assistance onto the piano bench and custom foot braces for pedal access.¹⁸ He exhibited remarkable independence between right and left hands, enabling exceptional speed of execution.

Music practice may induce rheumatic diseases

Rheumatic diseases are a common cause of pain and disability, significantly impacting quality of life. Several musicians have been affected by these conditions. Musicians are prone to developing rheumatic diseases, either congenital or resulting from intensive practice and instrument overuse. The economic and social pressures faced by musicians often lead to a reluctance to seek medical attention, making it difficult to accurately assess the true prevalence of these conditions.¹⁹ The majority affect the upper limbs, impacting violinists and pianists most frequently. In large surveys involving opera musicians and orchestral players, the reported prevalence of musculoskeletal complaints severe enough to impair performance ranges from 64% to 76% (15). Table 1 lists some of the numerous pathologies caused by musical practice.

Table 1. Rheumatologic pathologies in musicians: causes, instruments and observations.

Category	Pathology	Related instruments	Main causes	Observations	Caused by musical practice
Sesamoid bones (16)	Hypertrophy of the sesamoid bones	Pianists	Intense training, early start	Larger in musicians, especially with early learning	Yes
Shoulder (17)	Rotator cuff syndrome	Violinists, flautists	Overuse, poor posture	Primarily affects the right shoulder	Yes
Wrist (17)	Tendinopathies, carpal tunnel syndrome	All instruments, especially strings and piano	Repetitive movements, muscle overload	second most affected area after the shoulder	Yes
Thumb (18)	Carpometacarpal osteoarthritis	All instruments	Excessive pressure, overuse	Can be relieved by a splint	Yes
Forearm (18)	Intersection syndrome (‘drummer’s wrist’)	Percussionists	Rubbing of extensor muscles, repeated tension	Pain at the intersection of extensor muscles	Yes
Joint hypermobility (18)	Musculoskeletal pain	All instruments	Excessive use of specific joints	Advantage for some joints (fingers), disadvantage for others (back, knees)	No
Fatigue and general pain (18)	Chronic pain, muscle weakness	All instruments	4–5 hours of daily practice, hypermobility		Yes
Spine (20)	Scoliosis	Violinists, cellists	Untreated asymptomatic scoliosis	Compensatory twisting of the cervical spine	No
Arm (19)	Compartment syndrome	Violinists	Overuse	Pressure from the instrument on the arm	Yes
Overuse syndrome (18)	Cervicalgia, shoulder pain, upper limb pain	All instruments	Excessive practice	Includes terms like tenosynovitis, tendinitis, dystonia	Yes
Temporo-mandibular joint (19)	Temporo-mandibular pain	Violin, viola, trumpet, tuba, trombone	Instrument position	Vibration transmission, pressure on the joint	Yes

Unlike shoes or clothing, musical instruments are typically made in a single standard size, despite the considerable variation in performers’ body shapes and sizes.²⁰ The repetitive movements involved in playing, along with the prolonged muscular effort required to support the instrument in an unnatural position, predispose musicians to different patterns of musculoskeletal involvement, which vary according to the instrument’s size, weight and playing position.¹⁹ Sesamoid bones, around finger joints and under tendons, can have their growth influenced by musical practice. These small, round bones function like pulleys, reducing tension and distributing forces across tendons, which provide better stability, speed and security. Their ossification occurs at puberty, when musicians intensify training. A correlation exists between these events—musicians have larger sesamoid bones than non-musicians, particularly those who begin playing early. This adaptation may stem from tendon stimulation through keyboard training.²¹

Violinists and flautists are exposed to rotator cuff injuries, especially in the right shoulder, due to prolonged arm abduction. The wrist is the second most affected area; pianists can develop carpal tunnel syndrome and tendinopathies due to overuse. All musicians may experience carpometacarpal osteoarthritis of the thumb, caused by excessive pressure or overuse. Percussionists may develop ‘drummer’s wrist’ (intersection syndrome), characterised by pain at the intersection of the extensor carpi radialis, the extensor pollicis brevis and the abductor pollicis longus muscles in the forearm. This results from repetitive movements and simultaneous wrist and thumb extensor tension.²² Excessive training, up to 4–5 hours daily, can lead to muscle fatigue, weakness and chronic pain.⁸

Violin practice can also contribute to compartment syndrome due to muscle overuse and arm compression against the instrument.²³ The injuries of violinists and flautists are related to a poor positioning of the shoulder blade, which plays a major role in the musician’s posture and ensures maintenance of the body’s balance during upper limb movements.

Overuse syndrome can affect all musicians and any body part, with a higher prevalence among women and string players. This term encompasses tendinopathies, tenosynovitis, cervical and shoulder pain, cervical-thoracic brachial outlet syndrome, cubital nerve lesions, interosseous nerve compression, superficial branch of the radial nerve compression and carpal tunnel syndrome. Moreover, wind instrument players may experience embouchure pathologies, and keyboard players often suffer from wrist and finger extensor issues, as well as lumbrical and interosseous muscle problems. String players experience strain on hand flexors and extensors. Further, violin, viola, trumpet, trombone and tuba players may experience temporomandibular joint disorders due to jaw pressure, masticatory muscle clenching or instrument-transmitted vibrations.²⁴

At the frontier of rheumatology, dystonia remains the main concern of professional musicians (rarely affecting amateur musicians), particularly pianists, guitarists and violinists. Other psychic problems, which can intertwine with musculoskeletal pathologies, must be kept in mind.

Occupational rheumatic diseases and their prevention in musicians

Every professional musician is at risk of developing occupational rheumatic diseases at any point in their career, potentially leading to alterations in their practice or temporary/permanent cessation of instrument use.²⁵ Occupational musculoskeletal disorders (MSDs) in professional artists, particularly musicians, were first comprehensively described by Bernardo Ramazzini in his book De Morbis Artificum Diatriba (Diseases of Workers), published in Modena in 1700 (1st edition) and Padua in 1713 (2nd edition). He attributed these ailments to biomechanical stress resulting from instrument overuse. While contemporary understanding acknowledges multifactorial aetiologies, including individual and psychosocial factors, biomechanical stress, particularly in combination with other risk factors, remains a significant contributor to MSDs in instrumentalists. Music performance anxiety is a major reported psychosocial risk factor for these diseases in professional musicians.²⁶

When professional musicians are affected by occupational rheumatic diseases, they may be eligible for compensation in countries with specific financial support programmes for work-related accidents or occupational diseases. However, confirmation of the occupational origin of these ailments is necessary for social insurance systems managing this funding. Due to the generally lower severity of these diseases compared with, for example, occupational cancers, financial compensation is often limited. Furthermore, the occupational prognosis is often poor for those forced to discontinue their musical practice, which is frequently a passionate pursuit.²⁵

To prevent occupational MSDs in musicians, it is crucial to increase awareness regarding physical fitness, correct posture and ergonomic adjustments in musical practice. A comprehensive assessment of all risk factors, from psychosocial to biomechanical, is essential to identify modifiable factors that could reduce the risk of conditions such as dystonia or rotator cuff syndrome. Even if challenging, particularly during training periods and immediately prior to performance, instrument use should be interspersed with frequent breaks in daily practice. Early recognition of occupational rheumatic diseases can also facilitate appropriate treatment, for example, in specialised musician health centres available in some countries,²⁷ where physiotherapists can provide targeted care for these professional players.

Conclusions

In conclusion, the potential of music as an alternative therapy for patients with rheumatic diseases deserves to be acknowledged and explored, but rheumatic diseases can significantly affect musicians, with consequences ranging from physical discomfort to the end of their careers. While some conditions like Marfan syndrome have enabled unique physical traits and exceptional skills, most musicians face challenges related to upper limb overuse and MSDs that impact well-being and performance. Therefore, further exploration of rheumatic diseases in musicians is warranted, particularly with an emphasis on the evolution of medical knowledge and clinical practices. These pathologies are complex and require specific treatment. Some European health professionals and musicians are training in the practice of ‘arts medicine’,²⁸ the first clinic of which was set up in France in 1989 by AF Arcier.