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Hey family, I need some help.

Maybe someone here has in their piano travels run across a name of a world renowned hand injury specialist (or equivalent) - in this case a piano player's hand injury. (?) I'm at the point where I might be willing to travel anywhere in the country to get a hand injury resolved. (I believe I recall maybe 20 years ago there was an old German classical pianist/teacher who specialized in pianist injury & injury prevention technique. Even "if" she's still alive, I can't seem to dig up who she was.) Any references or links to another forum which might have some folk who might have some references is greatly appreciated. At this point, piano career is over... But I guess I'm still compelled to give this one last try.

Thanks in advance for any help.

BACKGROUND (in case you're curious): Issue began in 2014. This might be a repetitive stress injury, but cause is unknown. Middle finger on right hand droops about a half-inch below the neutral position [fingers extended but relaxed] of the fingers, and has difficulty raising on it's own (quasi-autonomically).
Quasi-autonomically, in this context meaning for example when you press keys on the piano keyboard with your 2nd, 4th or 5th fingers - your other finger (in this case the 3rd finger will automatically slightly raise on it's own. You could call this peripheral compensation. But in my case, the finger does not raise at all in that context - and as such when playing scales for example the finger jumps bumps along all the black keys.

I've already run the gamut of doctors: GP, physiologist, EMG, hand surgeon (consult), hand surgeon #2, ultrasound [retinaculum appears normal], physical therapy, active release... No answer, no result.
If you're prepared to travel anywhere in the country, you would probably get a better answer if you specified which country.
[United States] But, if someone knows a name of a specialist in another country, I'm sure a consult/case review could be arranged.
You don't seem to have run gamut of piano teachers. You should have done that first.
Originally Posted by johnishere
At this point, piano career is over... But I guess I'm still compelled to give this one last try.

Sorry to hear this.

Take a look at this: John Hopkin's Center for Music & Medicine.

If you try this, or something else suggested by another member, do come back and update us on how you are doing.
Originally Posted by chopin_r_us
You don't seem to have run gamut of piano teachers. You should have done that first.

I'm not sure what you mean. ?
Piano teachers don't diagnose medical issues.
Feel free to elaborate.
It may be a technic issue. My fingers don 't raise as I use 2,3,4 or 5.
It sounds like you're talking about Dorothy Taubman, although she was American.
Can you raise your finger consciously (as opposed to what you call "quasi-autonomically")?
Originally Posted by chopin_r_us
It may be a technic issue. My fingers don 't raise as I use 2,3,4 or 5.

You're saying when you press one finger/key, and the other fingers not move? How do you learn to do or enable that?
Originally Posted by johnishere
I need some help.

johnishere, I sent you a PM (private message). You can find it at the upper right corner of the webpage immediately to the left of your "johnishere" forum handle. Click on the envelope-shaped icon.
How long have you been playing? Is this a recent development?
Originally Posted by johnstaf
Can you raise your finger consciously (as opposed to what you call "quasi-autonomically")?

Yes. I have pretty much full bulk motor control (full extensor strength), but not fine motor activation.

Here's another story example (in the rare off-chance that a piano player in future develops this problem and finds this forum):

One quasi-autonomic finger motion example is when you roll your fingers. This is when you tap your fingertips against the table/surface in a quick manner (as if you are impatiently waiting for your wife to finish getting dressed) in the 4-3-2, 4-3-2, 4-3-2 pattern. This motion can be done very quickly and can sound like a drum roll. From a technical aspect, 'conscious' or 'manual' motor control is not what enables you to do this motion because your brain is not capable of independently coordinating each finger, individually, that quickly. Instead, it's a semi-automatic (neurocognitive) process/sequence of your brain's motor control that enables you to drum roll your fingers that quickly.

However, in my case because the raising/extension of my middle finger is compromised - I have to consciously raise my middle finger under full manual control in each 4-3-2 sequence, which again is not the same type of brain motor control process as in the previous paragraph. So, if I try to do it quickly (automatically) my finger roll is a pathetic looking 4-twitch-2, 4-tried to raise a little-2, 4-slight twitch-2... you get the idea (by I 'can' do it manually slowly).

The speed of doing this finger roll manually instead of being able to do it automatically is the equivalent of a normal working hand rolling your fingers as described above, but this time use the finger pattern 5-2-3, 5-2-3, 5-2-3, etc. You'll have to 'manually' control each finger with that pattern, and it will be slower and more clumsy than 4-3-2. With much practice, 'some' people may be able to develop some quickness in doing this pattern, but most will never develop the same quickness as the drum roll sound of the 4-3-2 pattern.)
Originally Posted by johnstaf
It sounds like you're talking about Dorothy Taubman, although she was American.

It might have been. The first time I had paid attention to this teacher who specialized in posture-correct playing it was 15 or 20 years ago, and up to that point I had never had any physiologic issues - so I didn't really pay much attention to who she was. When I did a deep dive 3 or 4 years ago to try to find out who it was that I remembered, I ran across Taubman.... but for some reason it doesn't seem like that was her. Oh, and she was dead by then (2015).... so there's that.

For the record, I don't believe that a technique specialist pianist such as she would be able to diagnose my condition - but teachers who do specialize in technique tend to have worked with so many people that they may have come across at least one other person who has experienced the same condition/injury as mine, and might know the outcome of "that" person's years of trial and experiment before some genius doctor finally figured it out for them.

No need to reinvent the wheel if I can just borrow from someone else's long road of misery to get to their solution.
Originally Posted by Tyrone Slothrop
Sorry to hear this.

Take a look at this: John Hopkin's Center for Music & Medicine.


Yes, I did run across John Hopkin's a couple of years ago. My initial 'just an inquiry' with them didn't seem too promising... But, I have not crossed them off of the list.
Thanx much for that, I appreciate it.
Originally Posted by johnstaf
How long have you been playing? Is this a recent development?

Before this issued started 4 years ago, I played for 37 years without any issues. It was just coincidental that I had an understanding of muscular anatomy at that age when I first started playing (I was an athlete), so I knew better than to fray my finger tendons by constantly pulling them back and forth over a pile of stones... i.e. knew better than to play with a bent wrist where possible, as the constant rubbing of the flexor tendons against the retinaculum and wrist bones (carpal tunnel) could cause inflammation and/or long-term damage.

(ok, that "and" a little bit of vanity. After my first 30 days of playing, I couldn't 'play' like Horowitz... but I didn't want to 'look' like a rookie. So, I would sit up straight, posture looking good, arms and hands and wrist in proper alignment so that I could at least 'look' like a world class classical pianist..... while playing "twinkle, twinkle little star". hahahaha)
You might like to look up an experienced Taubman teacher. I don't know if they're uniformly good. However, they specialise in this kind of thing, and could probably point you in the right direction, as they will probably have seen this before.

They won't be able to cure a neuromuscular problem of course, but it would be good to talk to someone who really understands what you are talking about.

Originally Posted by chopin_r_us
It may be a technic issue. My fingers don 't raise as I use 2,3,4 or 5.

Nah, I don't think it's a technic issue. Most peoples' fingers are able to raise without any special technic training; and I don't remember any piano teacher ever mentioning to me that some of their lesson weeks were dedicated to "how to get your middle finger to raise'. The other reason I don't believe that it's a 'technic' issue is because some of my best friends are finger-raisers: people whose middle finger can raise... and they don't even play piano.

But, I'll admit - I'm curious: Which 'technic' are you using to get your fingers from the white keys up to the black keys without raising them? For example, at this point I can't even get a full 4 measures into "Jeux d'eau" without running into trouble having to raise my middle finger up to get clearance above the black keys at the same time that my 2nd finger is on one of the white keys [E#] as I play the finger crossover 32nd note diminished chord arpeggio motif in measure 4. And this is really a problem to get my fingers up to the black keys without raising them if I'm playing it in the style of Richter (196 MM). Or are you playing on one of those flat-rollup keyboards that they sell at Toys“R”Us? (That would explain why your "fingers don't raise as you use 2,3,4 or 5"... you know, since it's all... flat... and all.)

But, don't worry - I'm gonna keep working at fixing my finger... 'Cause being able to raise my middle finger would come in handy nowadays.
Originally Posted by johnishere
Originally Posted by chopin_r_us
It may be a technic issue. My fingers don 't raise as I use 2,3,4 or 5.

Nah, I don't think it's a technic issue. Most peoples' fingers are able to raise without any special technic training;


I very much doubt that this is a problem with your technique, as it only became apparent after many years of playing. You may need some special training in technique to overcome the problem, and that's why I think a Taubman teacher might be helpful.

I had a problem with my right hand, and my physio was able to help me. While my technique didn't cause the problem, I had to adapt to accommodate it. Your problem probably isn't as straightforward.
Originally Posted by johnstaf
... and could probably point you in the right direction, as they will probably have seen this before.

They won't be able to cure a neuromuscular problem of course, but it would be good to talk to someone who really understands what you are talking about.

Exactly, I'm sure that 'somebody' has seen this before.... I can't be the only purple alien who this has ever happened to. Although, with my dumb luck ?

I have a couple of assessment ideas as to what the problem might be, but unfortunately at this point guessing from the outside of the arm is no longer productive. This means "going inside". We'd have to open up the arm (surgery). But, because the specific cause is still not completely certain, that would be essentially experimental surgery - and I don't know if I'm at the point that I want to guinea pig this thing. On the one hand, I can currently play at about 70%* overall performance ability (some passages I can't really play well at all, but not every measure uses my right hand) - so, with experimental surgery it's at least possible that I could get back to 100% (or close enough)... But, on the other hand, open-arm surgery could also make matters worse.

* Keep in mind that if Pavarotti sang 'one' performance at anything less than 90% of his ability, every review in town would've said that he was a 'has been'; that he's all washed up. So, 70% kinda sucks.)
I read the opinion that the best hand surgeon in the USA is Dr. Scott Wolfe at the Hospital for Special Surgery.
Originally Posted by johnishere
Originally Posted by chopin_r_us
It may be a technic issue. My fingers don 't raise as I use 2,3,4 or 5.

You're saying when you press one finger/key, and the other fingers not move? How do you learn to do or enable that?

With a good teacher. I went through at least 6 before I fell into good hands.
Having read your longer reply you seem to be saying you cannot raise your 3rd finger at all. i.e. neither your extensor muscle or your intrinsic muscles work on that finger? If that is true what are your flexors doing during the attempt to raise - relaxed? or tense?
Originally Posted by chopin_r_us
Having read your longer reply you seem to be saying you cannot raise your 3rd finger at all. i.e. neither your extensor muscle or your intrinsic muscles work on that finger? If that is true what are your flexors doing during the attempt to raise - relaxed? or tense?

The muscle motor control circuitry in your body 'sort of' has two circuits like a furnace: a bulk motor control (conscious, manual, "just go ahead and lift your finger") actions, and fine motor control (the automatic actions which control things like when you hold out your hand and splay your fingers, you don't manually decide on how much muscle to activate to each finger to get them to lift and spread - your brain does it automatically).
(Flexors are relaxed; no apparent muscle imbalances.)

In my case, I can raise/extend the finger if I just stick out my hand and then decide to raise my middle finger. 'But', if I were to put my hand in the neutral position (fingers extended but relaxed) with my fingers hoovering a hair above the black keys, my middle finger is drooping about a 1/2 inch. So, if I then try to play a scale, my middle finger is just bumping into the blacks as I move my hand sideways along the keyboard; it's not raising up high enough to get past the black keys.

The brain, being as dynamic as it is, then automatically sends 'more' signal to the hand to get the middle finger to raise, which does raise the finger very slightly, but the muscles of the forearm/fingers are a common muscle group - so the more signal sent to the middle finger causes more signal to go to the other fingers. And in this example, my 4th finger starts to raise way up.... brain sends more signal since the middle finger still isn't quite high enough... 4th and 2nd fingers are now way up in the air.... you get the idea.

And at that point there is now so much signal/force/straining to get that middle finger up (the brain is doing all of this automatically) that 'all' of the fingers are tense, tight and at that point it's starting to look pretty nasty like a cerebral palsy pianist (not pretty) [sorry to all of our CP community for that example.]

Note, that this also applies to white keys because (and this is one of those things you'd normally never think about) every time you press a white key, your finger has to raise back up to get in position to press the next key. My finger will raise back up after pressing even the white key notes, but sluggishly. So, for certain passages that require wide hand spreads I wouldn't be able to raise 'and' laterally move the finger into place to where the next keypress will be. And the further you spread your fingers (as in playing thumb-pinky octaves or wide arpeggios), the more difficult it is to independently raise/control just one of your fingers at a time. The real example: It's kinda like trying to spread your fingers as wide as possible, and while holding them there try to relax 'just' your middle finger. You might be able to 'move' the middle finger, but you can't control/relax it.
Thanks for taking the time and patience to be so clear! and I'm very sorry for your problem. Firstly, do you realize there are two different schools of thought re common key depression? Most schools retain the shape of the finger moving from the knuckle only. A small number (including myself) change the shape of the finger as the key descends - for learners I describe this as scratching. To begin with do you know which you do? Have you tried the other?

Secondly, the extensors are only 1/10 the power of the flexors (a hand transplant surgeon told me that) but they have to control the flexion of the fingers. Likewise the flexors have to control the motion of the extensors. Without these action on command the fingers would curl instantly or extend instantly (same source). Does that help you diagnose better?.
Originally Posted by chopin_r_us
To begin with do you know which you do? Have you tried the other?

Being somewhat of a science geek when I first started playing, I experimented with several manners of technique as it pertains to kinematics and physiometrics. I believe it correct to say that regardless of which type of motion - single joint or multi-joint - a player principally employs, that due to the variation of mechanics necessary to play any one composition you end up using both methods at some point or another. That philosophy also includes even having to use the occasional flat-fingered passage. I also like varying the physical method of playing because it helps to avoid fatiguing out from the constant same position of using only one method primarily. And also for the reason I believe that each method can color the notes differently.

In my case, I tend to use both single-joint and multi-joint. Although, if you are one who subscribes to the idea of full body resonance, then single-joint fingering better allows for [the sensation] that the sound can vibrate back through the hand, up through the arm and your body becomes an extended resonance chamber of the instrument. That is less achievable, one could argue, using the slightly less supported multi-joint, 'scratch', 'peck-and-pull' or whichever phraseology that one wants to use.

Lately, on the odd occasion that I do sit at the piano, I'm using a bit of exaggerated curve of the hand [say occasionally Martha Argerich] - since this puts the fingers in a somewhat stretched under position - which means that it's easier to try to raise the finger from that position. (As opposed to a flat hand, which means the fingers are already partially raised out straight - which means it takes even more effort to raise the finger further up and back to flat.) I guess this position would be consider "the ostrich method".... 'cause in order to press the notes you're kinda stabbing down at the keys with your finger, like an ostrich sticking his head in the sand. hahahaha
Originally Posted by johnishere
I believe it correct to say that regardless... that due to the variation of mechanics necessary to play any one composition you end up using both methods at some point or another.
Not my experience. All the players I've viewed over a life time do one or the other. It can be had to tell which is being used if there's no visible difference. No research has been done to my knowledge to say how much intrinsic muscles vs flexors each coordination uses - scratch or ostrich. Which is much the pity.

So, you realize as you raise your finger the flexors are working to smooth the action? Are your flexors working too hard? Finger 4 due to it's peculiar extensor tendon arrangement is usually the problem.
Have you tried using kinesiology tape? It seems you can try using it both ways: to help your finger retain normal position and retrain proprioception or to deliberately flex it in order to make it strive to raise.

(I'm not a doctor.)
Originally Posted by chopin_r_us
No research has been done to my knowledge to say how much intrinsic muscles vs flexors each coordination uses - scratch or ostrich. Which is much the pity.

Thanks to technology, there have been a few (not many of any worth) dynamic MRI and EMG studies of hand motion keyboarding. Some have attempted to do a computational modelling of same. Notwithstanding the advancements in AI, don't expect a C3PO concerto anytime soon.
Originally Posted by chopin_r_us

So, you realize as you raise your finger the flexors are working to smooth the action? Are your flexors working too hard? Finger 4 due to it's peculiar extensor tendon arrangement is usually the problem.

Yes, the antagonistic muscle pair of the forearm should under normal circumstances have a natural balance and symbiosis. In my physical and sport endeavors I've always been mindful of avoid muscle imbalances and bilateral imbalances in general; same for my hands. This is important for anyone who often does heavy lifting, as the much larger and stronger flexor muscles (superficial 'and' deep) can easily dominate the hand. While I'm comfortably confident that my muscle pair is in adequate balance, "one" of the several concerns I have pertains to the palmar fascia in that hand. Just like bones and tendons get old with the rest of you, I believe that biochemical changes within the body as you age can affect secondary musculature structures such as the palmar fascia. Just like your skin can change from young and pliable to old and 'tight' and leathery as you age - I believe that the same can occur to the fascia. (Yes, I've assessed and ruled out Dupuytren's and a couple of other similar conditions.)

As said earlier, the only way to find out if the palmar fascia, or tendon sheaths are abnormal, and/or if adhesions of the superficial fascia are present (these are all very difficult to detect through ultrasound) would be to open that sucker up.... Maybe see if I can find a forearm rebuild kit on eBay and change out some bushings, gaskets or 10W30 wrist oil.
Overuse injuries take many forms that's why I think you should see a pianist who knows before going for opening up. Fascia doesn't tend to be involved.
Originally Posted by chopin_r_us
Overuse injuries take many forms that's why I think you should see a pianist who knows before going for opening up. Fascia doesn't tend to be involved.

Yeah, there's where the problem comes in: After a GP, physiologist, 2 different hand surgeons, an EMG, an ultrasound and a couple of approaches of physical therapy couldn't identify the problem - my confidence is low that anyone could 'rough guess' it.. or that "exercises" can simply make it start working again.

Muscular adhesions - binding of parts of the muscle to the fascia or to the tendon sheath are very common, and methods such as IASTM ("Graston") and active release are specifically employed to address the issue. It's not a question of "if" an individual experiences adhesions - they are very common - it's more of a question "in what manner and to what extent" is the effect of the adhesions. In large (and strong) muscle groups such as the quadriceps, even a significant amount of adhesions would not prevent the muscle from moving. Normal people and athletes walk around every day with adhesions and don't even know it.

But, for smaller muscles and those which require fine motor control, even small disruptions of the fascia or tendon sheath can throw off the normal function - though again are very difficult to determine on an ultrasound/MRI (since they don't have significant density different than the surrounding normal tissue.)

Again, for the purpose in case someone finds this post in the future:
As it pertains to adhesions, another of the few possible suspects in my case pertains to adhesions which affect the nerves [neuromuscular]. An adhesion could be described as merely an accumulation of "sticky" on your muscle sticking your muscle to its fascia or tendon to its sheath. So, think of it as an adhesion would be when a piece of gum sticks two pages of a book together in one spot on the page. Now envision a similar 'metal' piece of gum which falls on one spot on a circuit board - it would 'short circuit' the electrical path. 'That' would be a neuromuscular adhesion. A short circuit of the signal that the brain is sending to the middle finger - so it never gets there or is shunted (short-circuited) with the other finger (forearm) muscles. It's a "little" exotic, though possible... and at this point there just aren't many other observable explanations other than the nerve just "died".

You'll find it 'theorized' in many sports medicine manuals that this is possible, though you may not find it as common that many a doctor has actually confirmed many cases of it.

At the end of the day, even "if" a doctor, or pianist, or whomever were to have an "idea" of what's going on - it would still be at best an educated hypothesis. I'm mentally just not at the point yet of opening up the arm 'just for kicks' at this point. Not until I at least see 'some sort of' reasonable idea at what's going on and good reason to do so. Ironically, "if" I get to the point where I've accepted that I am no longer a pianist, 'then' I'd be more willing to open up the arm since it won't matter at that point if we open it up and it ends up making it worse.
Originally Posted by Iaroslav Vasiliev
I read the opinion that the best hand surgeon in the USA is Dr. Scott Wolfe at the Hospital for Special Surgery.

That's a very good reference, Iaroslav. I've looked into his bio, history and reviews - and I will put him very near the top of my list for now. Logically, there's not gonna a be a "drooping middle finger specialist" out there somewhere, so I'm not looking for a magician. Just looking for someone highly skilled, intelligent, with a good track record as that might give me the best chance at a good outcome.

Thanks a million.

P.S. Dude does have his own website. I'm not easily impressed by superficial things, so a website doesn't mean anything special. But, for a "hand doctor" to have his own website, with a ton of specialization, years of experience and a long pedigree of good outcomes ... that's kind of the equivalent of a Beverly Hills plastic surgeon for boob jobs.
Why are you convinced that you need to be able to "raise" the 3rd finger via the sagittal plane motion of the fingers?

Movement in the sagittal plane isn't the only way to exit (or enter for that matter) the keys. Once people start actually thinking about what needs to happen in all three planes of motion, it literally changes the game that's being played.

I'd need to think more carefully about what may be going on in your case because there is pathology going on, but just for communication's sake, I'm going to repost a couple of things I wrote on another forum to give you some background context about how differently I think about things.

Most of these I wrote awhile back, so there might be a few things I might quibble at and adjust for clarity, but I'm to lazy at the moment to check them in detail.

----

1) Piano playing is ballistic. This implies that there is a perfect timing and aiming that has to occur on every articulation. And yes, "direction" does indeed matter. It should be like a perfect game of pool, but with the stricter condition of already being aligned and primed to hit the ball the precise moment it "stops" every time. Not a split second before or after.

2.) It needs to respect motion in all three planes (triplanar motion). It requires you to learn how they interact and how to optimize them as related to the above point.

----

I have a strong intuition that I would need to more carefully verify (outside of extra pathology), that the issue of what we're really going after for the necessary ("specific" I believe to be a far better word for what we want than "independent") finger activity is actually more a neurological issue. By this, I mean it involves providing the body the exact, precise sensory information it uses to orient itself in space to specify the muscle activation we want. I'm going to simplify this to proprioception, though there is more going on.

Forces such as gravity and ground reaction forces are critical to providing this information because they give direction meaning. This point is so easy to gloss over because we lived and evolved in a world where these things are a given. Our human structure, evolved in such a way to make use of these forces to accomplish action; hence, the "design" of joints and the direction/type of muscle fibers are regulated by the responses to these forces. [Again, I'm greatly simplifying.]

In order to obtain the necessary, appropriate finger activity, the sensory context provided must be optimized for its particular situation. The state of the total joints (and muscular relationships) of the body must be in a position that is optimized for this. What people call "alignment", which is not merely a vague abstract thing, but a genuine sensory experience, is the instantiation and recognition of the contextual sensory information that provides the precise activity we want.

(For simplicity I'm not going to discuss the thumb at the moment, and I'm focusing on single note playing.)

Flexion in the sagittal plane aligned with keys (think tapping) is all you really need in terms of finger activity, but if you take a look at a relaxed hand, the plane of flexion for each finger are not at all parallel with each other or at the same "level" due to different lengths. Thus, the optimal position for precise finger activation requires tri-planar adjustment on every articulation. If you understand this point, then it becomes obvious that we can't correctly train the fingers without first training the coordinations to get them in the right spot, at the right time, with the appropriate muscle/joint states in the first place.

If people really understood how hard the last sentence can be to achieve (especially with most approaches), then they can finally start making the shift necessary to actually practice for real rather than relying on chance. The mere act of playing or doing anything at the piano to accomplish a physical task provides some initial sensory stimulus for motor learning, but there is always going to be a point of limiting returns until you update your model of "what has to happen and be felt".

-----
Response to the question:
How do you learn to develop lighter, more delicate fingers for fast pieces?

By actually setting them up to work.

They have the most control and speed when you limit their use to flexing in the sagittal plane. (Think just tapping.)

And yet, when you really think about it, that plane of motion is not where most of our work has to be. Distance on the keyboard is perpendicular to it in the frontal plane (horizontal)!

Now actually look at your hand. You're fingers have different lengths. They have different heights on the arch. Heck, the thumb sits in a radically different spot from the rest of them. (Count the joints starting from the end on the finger tips. The third joint for the fingers meet in a bridge at the main knuckles. The thumb's third joint is at the wrist.) They all sit in a different spot left-to-right as well.

Combine this with the contour of the keyboard, and is it not reasonable to suggest that we have to account for all these differences when going from one finger to the next if we want consistent control?

Now it seems obvious, but you actually have to be on "top" of a key to articulate it. This suggest that optimizing the above parameters has to happen before we articulate. The skeletal structure of the fingers has to be set up for success before they articulate.

Integrating these chains of thoughts it suggests the following:

1. Minimize if not outright get rid of the activity of the fingers in terms of their role of getting from key to key in the frontal plane so that they can actually work in the sagittal plane.

2. Optimize the activity of everything else that is involved in the frontal plane to get from key to key. These are the actions "in-between" tones and thus precede the next articulation. Thus an important end-point is to get the fingers in optimal position for leverage.

3.Optimize the timing and flow between these two parts. Timing and your speed of perception to it (and thus the reaction coordinated to it) are going to be the real rate-limiters. Every articulation (really the split-second before it) should have a perfect sense of balance from tip to chair-seat.

----

Find a trashcan and crumple up a paperball to play paper basketball.

Strategy 1: Get up from your seat and carry it over to place in.
Strategy 2: Actually shoot it in.

The perception of slow fingers outside of pathology usually comes from coordinations that effectively do the equivalent of Strategy 1 when you should have been training Strategy 2.

Strategy 2 involves inaccuracy that takes time, training, and focus to overcome and doing Strategy 1 is never, ever going to train what has to be done.

When people are first shown how Strategy 2 works at piano, they usually don't even believe it's possible, which is why it can take time to develop because it's full effect can't happen until you get get rid of any trace of Strategy 1. (Even people who making significant headway overcoming strategy 1 will continue to have eureka moments where they realize that they are still using Strategy 1. It usually ends up being stripped off in layers.)

Needing warms-ups just to obtain speed is usually symptomatic of Strategy 1. Their need is usually a strong indication of fingers habitually being used to manipulate distance at the keyboard rather than simply articulating and/or an upper arm that is being too controlled rather than free.

The real benefits of "warm-ups" are better experienced as "set-ups".

They should actually slow you down so that you can re-orient or calibrate yourself to the balance of the piano mechanism, spatial and dimensional relationships, dynamic postural balance (as opposed to static), and simply allowing to the body to find itself.

----

Also, the sagittal plane, which people are obsessed with, shouldn't be your primary reference for "power"; if anything, you're attention to it should be more towards "coming to a stop/equilibrium" or even "deceleration".

The frontal plane is really the source of power (because of the ease at which we can laterally destabilize), and transverse plane activity mediates the delivery of this power to the sagittal plane.

-----

A "glued" fourth finger is not a physical limitation that causes the underlying problem. The inability to get the fourth finger in an aligned position with correct timing (both in regards externally to the key action of the piano as well as internally to "yourself") is the problem. This is a tangible, learnable motor skill, not a structural issue that is overcome by structural development/alteration. Don't blame the inherent structure of the body for activating multiple fingers or any sort of muscular activity you don't want, when you put it a sensory state where it has no choice but to do so. Correct practicing first involves identifying the sensory states that produces the outcomes you want and then creating a replicable process that consistently reproduces them. (As well as identifying and avoiding those that you don't want.) This is independent of whatever you decide to practice.

"Flexibility" in terms of joint range of motion is not nearly often the actual issue that people think it is unless you've had long standing history of compensation and pathology. The real underlying issue comes from muscles that are perpetually "on" even in positional states where they should be ideally lengthening rather than contracting due to inappropriate compensatory activity. As I discussed somewhere else on this thread, it usually is a result of a failure or inability to "pick a side" to "transition to the other side".

"Enough stamina"

This is not an energetic issue or a cardiovascular one. I can near guarantee that anyone who complains of stamina issues is actively working against themselves because of what I discussed above. Humans have redundant ways (degrees of freedom involved in movement) of performing activities, but some of these are "emergency" options when your body has no other choice. The issue is that people constantly "live" in these emergency strategies because they never learned to appropriately deal with instability (roughly, learning how to "fall" correctly).

In any case, limitation is not a necessarily a bad thing.

"Faulty training only accentuates the muscular and neurological contributions to the habitual imbalance. Most often the faulty movement patterns are an exaggeration in one direction of a limitation in another direction." - Shirley Sahrmann

Proper motor learning will usually require people to actually become "more limited", first, because we need to remove layers of initial compensatory movement patterns that are getting in the way. Limitations are often built into our structure so that one side/segment of our body is more "aware" of where it is via proprioception so that you can freely move another side/segment. The issue is that people get "stuck" because they did not appropriately learn the correct strategy to transition to the other side so that different side/segments are able to reciprocate within their ranges of movement and alternate their roles from side to side.
Originally Posted by anamnesis
Why are you convinced that you need to be able to "raise" the 3rd finger via the sagittal plane motion of the fingers?

I appreciate all the info, and will read it... 'cause I like all info. But, in my case you can trust me when I say: finger ain't working. You'd be surprised at just how much disruption that this slight inability causes to the entire hand. It literally changes the dynamic of the rest of the entire hand - because the other muscles are automatically trying to compensate.

In the normal process of movement, your brain receives feedback from your muscles - and when you're trying to raise your finger.. and your brain is not receiving the feedback that the finger is raising, your brain continuously adjusts by sending more force to the finger control muscles... which by that point the extra force is causing the other fingers to tense up/lock up... (a sensorimotor gang bang) which then makes it very difficult to play freely with the other fingers... and all of this is happening in real time... during every sequence of notes that you're trying to play.

You can't play your next note, if your finger does not raise back up freely from the key you just pressed.
Originally Posted by johnishere
Originally Posted by anamnesis
Why are you convinced that you need to be able to "raise" the 3rd finger via the sagittal plane motion of the fingers?

I appreciate all the info, and will read it... 'cause I like all info. But, in my case you can trust me when I say: finger ain't working. You'd be surprised at just how much disruption that this slight inability causes to the entire hand. It literally changes the dynamic of the rest of the entire hand - because the other muscles are automatically trying to compensate.

In the normal process of movement, your brain receives feedback from your muscles - and when you're trying to raise your finger.. and your brain is not receiving the feedback that the finger is raising, your brain continuously adjusts by sending more force to the finger control muscles... which by that point the extra force is causing the other fingers to tense up/lock up... (a sensorimotor gang bang) which then makes it very difficult to play freely with the other fingers... and all of this is happening in real time... during every sequence of notes that you're trying to play.

You can't play your next note, if your finger does not raise back up freely from the key you just pressed.


To clarify, I'm asking why you think that is the only way to get the finger up freely to escape the key. The transverse motion of the forearm allows you to laterally destabilize in the frontal plane to escape from the key.

Take your right hand. Pronate/roll over and past your thumb nail against a contact resistance (table/keys/whatever) as if winding up/loading a spring. This should lift all the fingers.[If you can, find the sweetspot when pronating right before your upperarm starts to "chicken wing"] In your right hand, wind up the the rotation to the left so that it ballistically sends it to the right and let it fall without interference. Don't control it mid-flight. The windup determines how and where it should land.

Similarly supinate it all the way to the point that your hand is palm up in supplication, but again use the wind-up in supination to launch it and let it fall to left exactly where you want it to land. (Think angry birds. Again, don't try to affect it mid-flight.)

[As an aside, re-read the above, and consider the implications with regards to dynamic/sound control. The timing of where you primarily control sound doesn't happen at articulation, but in the "wind-up/launch" that comes before it in the opposite direction. Trying to manipulate it at the moment of contact is already a split second too late and just leads to inconsistencies. ]

Trying to escape the key primarily in the sagittal plane causes far more issues, and it's not even really how we are built when you metaphorically compare it to what has to happen in gait. It's also doesn't easily relate with musical concerns because the timing relationships between articulation and the motions getting you from key to key (by exiting and entering) doesn't intuitively connect or coordinate easily.
Originally Posted by anamnesis

To clarify, I'm asking why you think that is the only way to get the finger up freely to escape the key. The transverse motion of the forearm allows you to laterally destabilize in the frontal plane to escape from the key.

I think that you're over-complicating your interpretation of my description.
Check this one out:
1) Put your right hand on the keyboard in a basic C scale position; hand and fingers relaxed with finger tips lightly touching the keys.
2) Now play: Thumb plays 'c', 2nd finger plays 'd', now play 'e-flat' with the 3rd finger..... How you gonna do that if your finger's not raising up to get to the black key in order to press it?

A finger being able to support itself and to raise is a normal, and very necessary part of playing piano. All my other 9 fingers can do it. All 10 'used to' be able to. But, not now.
Originally Posted by johnishere
Originally Posted by anamnesis

To clarify, I'm asking why you think that is the only way to get the finger up freely to escape the key. The transverse motion of the forearm allows you to laterally destabilize in the frontal plane to escape from the key.

I think that you're over-complicating your interpretation of my description.
Check this one out:
1) Put your right hand on the keyboard in a basic C scale position; hand and fingers relaxed with finger tips lightly touching the keys.
2) Now play: Thumb plays 'c', 2nd finger plays 'd', now play 'e-flat' with the 3rd finger..... How you gonna do that if your finger's not raising up to get up and above the black key in order to press it?


1) This is already a problem, one that most people refuse to realize. When playing single notes, you can't actually get perfectly aligned behind each one with even trace "holding" of a position that doesn't commit to really being behind a finger. This isn't actually a relaxed position.

2) When you aren't affected by the problem of 1) and actually move behind each key in other planes of motions I've alluded to (you may need to visualize a transverse section of the forearm to really understand the motions going on here), then 2) isn't a problem at all.

-------------

The fact that I see 1) as a problem and that most people probably don't, should tell you that how I think playing occurs is quite different. You're forcing stability that you haven't earned, and you've reduced the degrees of freedom available to you that you actually need. Without those degrees of freedom, you won't be able to get over the black keys. It's like trying someone trying to get from Europe to the Americas by land and sea, and having no idea that air travel was available.

[Take two pens together in your right hand, parallel to the keys, with one being more left and another being more right. While make contact with the D with the left most pen, roll to it left, but again with a sense of wind up, while noticing that the right most pen has to concomitantly go up. Pay attention both to the left end rotating with contact and the rising of the right end so you can control where the right end falls to the right on top of the Eb.]

Many people re-training from injury end up having to obliterate any trace sense of 1) because it gets in the way. It's a common problem that is unfortunately ingrained due to many beginner pedagogic approaches.

In efficient gait, you're swing leg doesn't support itself. The collateral leg making contact with the ground does. We take advantage of alternating lateral instability and stability.

Originally Posted by johnishere
Hey family, I need some help.

Maybe someone here has in their piano travels run across a name of a world renowned hand injury specialist (or equivalent) - in this case a piano player's hand injury. (?) I'm at the point where I might be willing to travel anywhere in the country to get a hand injury resolved. (I believe I recall maybe 20 years ago there was an old German classical pianist/teacher who specialized in pianist injury & injury prevention technique. Even "if" she's still alive, I can't seem to dig up who she was.) Any references or links to another forum which might have some folk who might have some references is greatly appreciated. At this point, piano career is over... But I guess I'm still compelled to give this one last try.

Thanks in advance for any help.

BACKGROUND (in case you're curious): Issue began in 2014. This might be a repetitive stress injury, but cause is unknown. Middle finger on right hand droops about a half-inch below the neutral position [fingers extended but relaxed] of the fingers, and has difficulty raising on it's own (quasi-autonomically).
Quasi-autonomically, in this context meaning for example when you press keys on the piano keyboard with your 2nd, 4th or 5th fingers - your other finger (in this case the 3rd finger will automatically slightly raise on it's own. You could call this peripheral compensation. But in my case, the finger does not raise at all in that context - and as such when playing scales for example the finger jumps bumps along all the black keys.

I've already run the gamut of doctors: GP, physiologist, EMG, hand surgeon (consult), hand surgeon #2, ultrasound [retinaculum appears normal], physical therapy, active release... No answer, no result.

Hi Johnishere,

Sorry missed your post I thought it was one of these joke threads.

I read over your posts with some interest. These kind of problems can be result in these types of medical wild goose chases. They are looking at the level of the musculoskeletal system- the fascia, adhesions, joint mobility, etc.- possibly in all the wrong places. Your brain is working well so I wouldn't worry about any fine motor control issues. There are two places that can a paresis like this: either at the cervical spine (the C7 myotome) or a peripheral nerve. I'm assuming you don't have numbness or tingling (paresthesias) shooting down your arm or would have reported that by now. So I think it's coming from a peripheral nerve.

You most likely have posterior interosseous nerve entrapment. This is the nerve that enervates the extensor digitorum communis the muscle group that extends the fingers. You've heard of drop foot? Well I think you have drop finger. You can get posterior interosseous nerve entrapment from blunt force trauma to the proximal dorsal surface of your forearm BUT there is another common way to get this syndrome- through long term repeated supination/pronation of the forearm/wrist with the wrist extended. Supination pronation is the rolling we do with our forearms when we play music that requires rolling between fingers 1 and 4/5. If you play with your wrists higher than your fingers as some professionals do I can see this happening. The nerve gets entrapped in the supinator muscle of the forearm. Most patients I have seen have far worse symptoms that involve weakness with wrist extension as well. Perhaps a branch of the posterior interosseous nerve is involved in your case only. Normal treatment is too rest, wear a brace, perform radial nerve glides, and in some cases inject cortisone proximal to the supinator muscle. Yours may be long term and might have caused permanent nerve damage (not serious overall but affecting your piano playing). Perhaps the EMG missed this.

Anyway talk to a neurologist and work with a therapist who can teach you radial nerve glides. Good luck.
Originally Posted by Jethro
Hi Johnishere,
These kind of problems can be result in these types of medical wild goose chases. They are looking at the level of the musculoskeletal system- the fascia, adhesions, joint mobility, etc.- possibly in all the wrong places. I'm assuming you don't have numbness or tingling (paresthesias) shooting down your arm or would have reported that by now. So I think it's coming from a peripheral nerve.

You most likely have posterior interosseous nerve entrapment.

Perhaps a branch of the posterior interosseous nerve is involved in your case only. Normal treatment is too rest, wear a brace, perform radial nerve glides, and in some cases inject cortisone proximal to the supinator muscle. Yours may be long term and might have caused permanent nerve damage (not serious overall but affecting your piano playing). Perhaps the EMG missed this.


Thank you a million times for your time and insights, those are excellent assessments.
I have a question for you at the end of this post. I'm posting the next few paragraphs for posterity, but you can skip to the question at the end if you like.
-----------------------------------------------------------------

1) You're correct, Jethro - no numbness/tingling or any other indication of total nerve compromise.

2) Correct again, that very often a practitioner is looking superficially. Albeit, the human body is a fantastically complex machine - so I can cut 'some' slack in 'some' cases to a practitioner who is trying to figure out what the heck is going on. (I do tend to be, however, somewhat critical of western medicine approaches which too often are premised upon 'treat the symptoms', and not enough time spent understanding the 'root cause'.)

3) As you can imagine, I've replayed in my mind the entire time period as far back as an entire year before these symptoms started - analyzing for any clues. The interosseous muscle/nerve complex 'is' on my mental list of potential suspects for the reason that near the time that the symptoms started, I was spending quite a bit of time working on certain passages that involve reasonably wide finger spreads (wide and moving arpeggios). So, yes - you're are on track with that possibility also.

Spending much time working those passages means somewhat significant amounts of time that the interosseous muscles are being worked; that the fingers are continuously spread wide. Trying from memory, I wasn't able to recall that I had any particular fatigue from that specific work (I'm pretty certain that there wasn't any fatigue) - but, 'no presence of fatigue' doesn't rule out the possibility.

4) I agree that the EMG may have missed something. I've always had a low confidence in electro studies for 'this' type of paresis (though they are otherwise generally useful). If the whole of your hand is not moving, logically it would be very easy to assess if there is zero nerve conduction. But, with a slight paresis, or a fine motor control issue, or nerve 'branch' issue - you would need an 'extremely' high-resolution, or 'extremely' narrow-band filter, or 'extremely' precise probe placement to get an accurate assessment. Otherwise, as long as any reasonable amount of conduction is present a practitioner will likely assess the readings as relatively normal nerve conduction.

5) Lastly, I am sad-nervous that after this much time has passed (4 years now) without any change, that this may be a permanent affliction; that there may have been permanent damage. I did include neural glides (r,u & m just to be complete), along with (in progressive order):

a) cold/heat
b) massage
c) physical therapy (stretching, exercises, neural glides, etc.)
d) 3rd finger splint with 10 - 20 degree positive deflection (for stretching purposes to reduce the antagonist tension of the flexors, and to traction the extensor)
e) accupressure
f) myofascial release
g) active release*
h) IASTM (Graston)*
i) Most aggresive of all: Jedi mind meditation to gain Jedi control of the finger. (or let's just call it "meditation"; mind-body connection exercises.
[Coincidentally, I also ran a course of prednisone during this time period (asthma), which would've helped at least somewhat to determine if there was any hand improvement from the reduction of systemic inflammation, 'if' any was present. There was no perceptible improvement with the finger.]
[* Note: Due to the extremely intricate layout of the forearm musclulature, it is very difficult (in some regards not possible) to fully manipulate individual muscles/tendons.]
---------------------------------------------------------------

QUESTION: Jethro, you sound like you may have some clinical experience. As rare as this may be, have you ever run across a situation of "short-circuited" nerve conduction? (I believe I recall running across that scenario in the textbooks way back when, but I personally have not ever come across an actual case of this.) As mentioned in one of my previous posts, this would be a situation of an adhesion within the muscle or fascia which short-circuits the nerve conduction. This short-circuiting could either a) cause nerve signals to go to an adjacent muscle or muscle area, b) could shunt the intended muscle target (cause it to not activate), c) or both.

Here's the back history: The way that my condition manifested firstly, I was noticing that my 4th finger was raising pretty high as I pressed down my 3rd finger on a certain passage (of arpeggios). I've always had excellent finger independence, so I figured I had just gotten into a bad habit of some sort over time without realizing it. Figured I just needed to "focus" and practice better. However, from the first time I noticed that anomaly, it was over the course of about the next 4 months that the 3rd finger slowly got to the point of full compromise where it still is today - and it was then obvious that the 3rd finger extensor paresis was the main problem, not 'bad technique'.

BUT, I wouldn't confidently make that a conclusively assessment, because as it turns out "anytime" you strain to lift one of your fingers, the adjacent fingers may engage (raise up)/overcompensate [the whole sensorimotor/biofeedback mechanism].
[I eventually realized that my 2nd finger was also raising too high (when playing passages in the other direction) because it was also overcompensating and raising too high when the 3rd finger wouldn't raise.]

Determination of short-circuiting:
Initially this seemed at least somewhat as a plausible, though exotic, possibility. But, due to the fact that the 2nd finger 'also' (just like the 4th finger) exhibits the same sensorimotor peripheral finger activation when the 3rd finger won't raise , I am ranking this possibility as "low" on the list of likely causes.

Thanks a million again for your time and input.
Are you aware you fit the classic 'dystonic' type? Shouting it, in fact, all over this thread!
https://www.ncbi.nlm.nih.gov/pubmed/20795373
Originally Posted by chopin_r_us
Are you aware you fit the classic 'dystonic' type? Shouting it, in fact, all over this thread!

A) Thanks for the input. I'd say that after enough years of evaluative experience, most practitioners learn not to get bit by the shark of believing that a diagnosis was "shouting" its obviousness after merely an anecdotal description which doesn't even include other medical factors, or a physical assessment. Too many a time, such a preliminary educated guess turns out to be way off base. Even "if" a focal dystonia were a contributing factor in my case, I definitely would not be one to call it classic, since it presents in no 'classic' typical manner as most cases of dystonia. [See item "B" below.]

B) While I have not crossed dystonia or any other neuropathologies off of the possibilities list, the problem with an assessment of a dystonia is that dystonia typically tends to be a contraction disorder, which is the literal opposite of paresis or atony which are indicative of lack of ability to fully contract, as in my case. There has not been any indication in my case of any antagonist muscle group anomaly. Said more succinctly, pianist dystonia tends to be fingers curling under from the flexors contracting, whereas my condition appears to be from the opposite muscle - the extensor - not contracting to raise the finger.

But again, I'll keep your theory on my list. Now that I am restarting this process to try to resolve this issue (after somewhat giving up on it for a year or two), I'll hopefully have more answers as this moves forward.

Thanks.
Originally Posted by johnishere
Originally Posted by Jethro
Hi Johnishere,
These kind of problems can be result in these types of medical wild goose chases. They are looking at the level of the musculoskeletal system- the fascia, adhesions, joint mobility, etc.- possibly in all the wrong places. I'm assuming you don't have numbness or tingling (paresthesias) shooting down your arm or would have reported that by now. So I think it's coming from a peripheral nerve.

You most likely have posterior interosseous nerve entrapment.

Perhaps a branch of the posterior interosseous nerve is involved in your case only. Normal treatment is too rest, wear a brace, perform radial nerve glides, and in some cases inject cortisone proximal to the supinator muscle. Yours may be long term and might have caused permanent nerve damage (not serious overall but affecting your piano playing). Perhaps the EMG missed this.


Thank you a million times for your time and insights, those are excellent assessments.
I have a question for you at the end of this post. I'm posting the next few paragraphs for posterity, but you can skip to the question at the end if you like.
-----------------------------------------------------------------

1) You're correct, Jethro - no numbness/tingling or any other indication of total nerve compromise.

2) Correct again, that very often a practitioner is looking superficially. Albeit, the human body is a fantastically complex machine - so I can cut 'some' slack in 'some' cases to a practitioner who is trying to figure out what the heck is going on. (I do tend to be, however, somewhat critical of western medicine approaches which too often are premised upon 'treat the symptoms', and not enough time spent understanding the 'root cause'.)

3) As you can imagine, I've replayed in my mind the entire time period as far back as an entire year before these symptoms started - analyzing for any clues. The interosseous muscle/nerve complex 'is' on my mental list of potential suspects for the reason that near the time that the symptoms started, I was spending quite a bit of time working on certain passages that involve reasonably wide finger spreads (wide and moving arpeggios). So, yes - you're are on track with that possibility also.

Spending much time working those passages means somewhat significant amounts of time that the interosseous muscles are being worked; that the fingers are continuously spread wide. Trying from memory, I wasn't able to recall that I had any particular fatigue from that specific work (I'm pretty certain that there wasn't any fatigue) - but, 'no presence of fatigue' doesn't rule out the possibility.

4) I agree that the EMG may have missed something. I've always had a low confidence in electro studies for 'this' type of paresis (though they are otherwise generally useful). If the whole of your hand is not moving, logically it would be very easy to assess if there is zero nerve conduction. But, with a slight paresis, or a fine motor control issue, or nerve 'branch' issue - you would need an 'extremely' high-resolution, or 'extremely' narrow-band filter, or 'extremely' precise probe placement to get an accurate assessment. Otherwise, as long as any reasonable amount of conduction is present a practitioner will likely assess the readings as relatively normal nerve conduction.

5) Lastly, I am sad-nervous that after this much time has passed (4 years now) without any change, that this may be a permanent affliction; that there may have been permanent damage. I did include neural glides (r,u & m just to be complete), along with (in progressive order):

a) cold/heat
b) massage
c) physical therapy (stretching, exercises, neural glides, etc.)
d) 3rd finger splint with 10 - 20 degree positive deflection (for stretching purposes to reduce the antagonist tension of the flexors, and to traction the extensor)
e) accupressure
f) myofascial release
g) active release*
h) IASTM (Graston)*
i) Most aggresive of all: Jedi mind meditation to gain Jedi control of the finger. (or let's just call it "meditation"; mind-body connection exercises.
[Coincidentally, I also ran a course of prednisone during this time period (asthma), which would've helped at least somewhat to determine if there was any hand improvement from the reduction of systemic inflammation, 'if' any was present. There was no perceptible improvement with the finger.]
[* Note: Due to the extremely intricate layout of the forearm musclulature, it is very difficult (in some regards not possible) to fully manipulate individual muscles/tendons.]
---------------------------------------------------------------

QUESTION: Jethro, you sound like you may have some clinical experience. As rare as this may be, have you ever run across a situation of "short-circuited" nerve conduction? (I believe I recall running across that scenario in the textbooks way back when, but I personally have not ever come across an actual case of this.) As mentioned in one of my previous posts, this would be a situation of an adhesion within the muscle or fascia which short-circuits the nerve conduction. This short-circuiting could either a) cause nerve signals to go to an adjacent muscle or muscle area, b) could shunt the intended muscle target (cause it to not activate), c) or both.

Here's the back history: The way that my condition manifested firstly, I was noticing that my 4th finger was raising pretty high as I pressed down my 3rd finger on a certain passage (of arpeggios). I've always had excellent finger independence, so I figured I had just gotten into a bad habit of some sort over time without realizing it. Figured I just needed to "focus" and practice better. However, from the first time I noticed that anomaly, it was over the course of about the next 4 months that the 3rd finger slowly got to the point of full compromise where it still is today - and it was then obvious that the 3rd finger extensor paresis was the main problem, not 'bad technique'.

BUT, I wouldn't confidently make that a conclusively assessment, because as it turns out "anytime" you strain to lift one of your fingers, the adjacent fingers may engage (raise up)/overcompensate [the whole sensorimotor/biofeedback mechanism].
[I eventually realized that my 2nd finger was also raising too high (when playing passages in the other direction) because it was also overcompensating and raising too high when the 3rd finger wouldn't raise.]

Determination of short-circuiting:
Initially this seemed at least somewhat as a plausible, though exotic, possibility. But, due to the fact that the 2nd finger 'also' (just like the 4th finger) exhibits the same sensorimotor peripheral finger activation when the 3rd finger won't raise , I am ranking this possibility as "low" on the list of likely causes.

Thanks a million again for your time and input.

Yes you were on the right track and treatments with a lot of things I would have tried. My only question would be did they address the supinator muscle which is at the proximal aspect of the forearm. Soft tissue mobilization there, neural glides, cortisone injections or even surgery at times is tried to either bring down inflammation and/or release the entrapment.

As for adhesions causing short circuits, I've not heard of that before and I couldn't explain the physiology of why that would happen. I can see how adhesions could slow nerve conduction velocity much as if a piece of furniture was pinching a phone cord would impede the signal but cross talk (short circuit) is something different. It usually implies damage to the axon or competing signals in the central nervous system such as with epilepsy. For example in multiple sclerosis there are plaques that impede the signal down the nerve cell's axon. In a healthy nerve cell the nerve signal is accelerated down the axon by a physiological event called saltatory conduction whereby the electrical signal "skips" down the the axon along something like switch stations called "nodes of ranvier". This conduction is interrupted when plaque damages the myelin (fatty) sheaths that cover the axon and the signal is impeded or slowed. In epilepsy there is cross talk or competing signals sometimes between the left and right sides of the brain and the only way to sometimes stop this short circuit is to do a commissurotomy basically splitting the left and right side of the brain in extreme cases.

As for the loss of independence of the fingers, I think you are indeed utilizing overflow by activating the 2nd and 4th fingers to compensate for a possible signal loss to the 3rd finger. Overflow happens when you try to engage muscles that share the same nerve enervation. In this case fingers 2 and 4 are over excited because they share the same muscle group and enervation by the posterior interrosseous nerve,
If you do want to consult a Taubman teacher, the place to go is the Golandsky Institute. They can do online consultation, I believe, if there isn't a teacher in your area. They've had a lot of success with dystonias and other injuries.
I'm just saying how well your character fits the profile of a dystonia prone individual. That's what shouts out.
Originally Posted by Jethro

My only question would be did they address the supinator muscle which is at the proximal aspect of the forearm. Soft tissue mobilization there, neural glides, cortisone injections or even surgery at times is tried to either bring down inflammation and/or release the entrapment.

Yep, did quite a bit or work on both ends of the arm: fingers to elbow. This was for the obvious reasons, but also because in 2015, about a year after the finger issue began, I was starting to feel a very minor amount of lateral epicondylitis (tennis elbow). This is believed to be from working out, and it later became bilateral (in the left arm also) [those symptoms are gone now], along also with some tendonitis/tendonosis at the quadriceps (patella) a few months after that [I was 49 years old at that point, so those minor ailments alone aren't highly suspicious. But of course I made note of them for possible correlation.]

Since it was at least possible that there may have been some correlation between those two issues, I spent a good amount of focus on trying to :

a) 'Dig in' to get some manipulation/separation between all of the extensors, the supinator, pronator. Get those things moved around to make sure there were no trapped nerves in between the many muscles of the forearm, or irritated nerve pathways.

b) Some focus on active release to try to manipulate the tendon sheaths in case there were any adhesions there.

c) Work done (exercises, ice/heat) to ensure there was no impingement/compromise at the carpal tunnel.

d) Work/massage to the hand to make sure the interossei (both palmar and dorsal) and everything else wasn't getting 'stuck' together in some way, or being compromised there. [The interossei do act on the finger flexion/extension in a complex kinda way, so anything's possible as a cause.]
Also hand stretching and massage to make sure that the palmar fascia is loose and pliable - and not pulling against finger extension efforts.
If possible, I'd think it be interesting to see a video of you playing a scale or anything you've described. That's usually more telling than verbal descriptions.

Just based on the entire discussion so far, you've pursued most options short of surgery, localized cortisone, and (retraining using alternate strategies), and you haven't seen any noticeable results. Did any of the clinicians you've seen actually give a diagnosis or why they ruled things out? I'm just a bit surprised that you've run that gamut and none of them pursued dorsal interosseus nerve entrapment more.

But at the end of the day, what outcomes are you exactly hoping for? What do you consider to be your last shot? Would opening up the arm really be worth it just for a diagnosis if there were alternatives that solved or at least worked around the problem by minimizing the need for the extensors, even if you never got a clear answer about what was going on?

I'm actually now more curious about your training history, which you haven't really discussed. Were you trained/taught to use the extensors to lift the fingers like what's described in Hanon or even tabletop independence exercises?
Originally Posted by johnishere
Originally Posted by Jethro

My only question would be did they address the supinator muscle which is at the proximal aspect of the forearm. Soft tissue mobilization there, neural glides, cortisone injections or even surgery at times is tried to either bring down inflammation and/or release the entrapment.

Yep, did quite a bit or work on both ends of the arm: fingers to elbow. This was for the obvious reasons, but also because in 2015, about a year after the finger issue began, I was starting to feel a very minor amount of lateral epicondylitis (tennis elbow). This is believed to be from working out, and it later became bilateral (in the left arm also) [those symptoms are gone now], along also with some tendonitis/tendonosis at the quadriceps (patella) a few months after that [I was 49 years old at that point, so those minor ailments alone aren't highly suspicious. But of course I made note of them for possible correlation.]

Since it was at least possible that there may have been some correlation between those two issues, I spent a good amount of focus on trying to :

a) 'Dig in' to get some manipulation/separation between all of the extensors, the supinator, pronator. Get those things moved around to make sure there were no trapped nerves in between the many muscles of the forearm, or irritated nerve pathways.

b) Some focus on active release to try to manipulate the tendon sheaths in case there were any adhesions there.

c) Work done (exercises, ice/heat) to ensure there was no impingement/compromise at the carpal tunnel.

d) Work/massage to the hand to make sure the interossei (both palmar and dorsal) and everything else wasn't getting 'stuck' together in some way, or being compromised there. [The interossei do act on the finger flexion/extension in a complex kinda way, so anything's possible as a cause.]
Also hand stretching and massage to make sure that the palmar fascia is loose and pliable - and not pulling against finger extension efforts.

You've done pretty much all the conservative treatments available. There are more invasive approaches but they are not 100% sure this is due to nerve entrapment. A cortisone injection may help but that's a typical fall back when we don't know exactly what's going on, but the treatments tell me they are on the same page. I'm still leaning heavily towards PIN entrapment though and all those techniques may not fully address the situation. Have you tried rest or have you been practicing all throughout this ordeal?
Originally Posted by anamnesis
Just based on the entire discussion so far, you've pursued most options short of surgery, localized cortisone, and (retraining using alternate strategies), and you haven't seen any noticeable results.

Correct, no noticeable results.

Originally Posted by anamnesis

But at the end of the day, what outcomes are you exactly hoping for?

Just a normal (or close to normal) working finger. When a normal person puts his hand on the piano, presses finger 1 while simultaneously raising finger 3 to play a note with that finger, the finger normally does exactly that: it simply raises up to press the key. Mine doesn't, or does so only with strained effort, which distorts the other fingers away from a usable technique. Raising your finger is nothing complicated; no special technique require nor modification required, since this is a 'built-in app' for humans. You're born, and your fingers are able to raise in coordination with the other fingers. It's so easy even a caveman could do it.... And did, as of a few million years ago.

Originally Posted by anamnesis

What do you consider to be your last shot?

Without at least some indication pointing in a specific direction (like if there were tingling, numbness - that would 'at least' give a "some idea" specifically - a better than "experimental" chance at identifying a specific condition). Once I narrow it down, or it gets worse which 'might' make it easier to know what's happening - of what's 'not' happening. As of this day, there's not enough info to reasonably consider opening up the arm.

Originally Posted by anamnesis
Would opening up the arm really be worth it just for a diagnosis if there were alternatives that solved or at least worked around the problem by minimizing the need for the extensors, even if you never got a clear answer about what was going on?

I'm actually now more curious about your training history, which you haven't really discussed. Were you trained/taught to use the extensors to lift the fingers like what's described in Hanon or even tabletop independence exercises?

Same answer as above: This is not a "technique modification" issue; can't get the finger above the keys (or into position) without straining. Maybe 'after' if the finger starts working again,I'd look at if there has been something deleterious in my technique to prevent this from happening again. But, as I said in an earlier post: I've played for 37 years with no issues to speak of before this started 4 years ago.

FUNNY BUT TRUE (and a perfect example of what I'm talking about):

With all of my explaining about "wide arpeggios", I was inspired to revisit what I've been describing here - so I sat down at the piano (I do so only occasionally nowadays). Guess how much playing it took before my problem to become apparent: Zero seconds. Here's how:

The only composition with any wide hand positions that I had been playing around the time that this all started is Jeux d'eau (Ravel). There's a specific passage (the cascade somewhere around measure 12 or 14 I believe) with some wide-arpeggios wherein the very first 3 notes encompass one full octave: D(6) - A - D(7) (then A(7) Fingering is 1-2-3-5). In order to play that passage relatively quickly, as soon as you place your hand on the keyboard, fingers just brushing against the top of the keys.... before you even play the first note your 3rd finger needs to be floating just above the keys and slightly moved off axis and ready to point toward D(7). Otherwise, there's no way you can move your entire arm sideways to cover the distance. (It'd be nice if composers wrote everything as c-d-e-f-g-f-e-d-c, but we know that is not the case.)

AS SOON AS I put my hands on the keyboard, with my 1st finger and 2nd finger in place, I had to strain to raise the 3rd finger up and slightly off axis to get it in position 'before' I even played a note. This something that normally happens automatically; your brain just does it.

It's one of those things that is so automatic, that you can't imagine how much you 'can't' do without it. Your flexor and extensor muscles are in such a normal balance, that it generally should not require any effort to simply hold out your fingers as they brush against the top of the keys. My 3rd finger just kind of lays on the key since it is not supporting on its own.

Talk about a pain in the

Yes, I "can" hold out my fingers and get them all level. But, for normal hands, you should not be using much muscle at all to do so. In my case, all my other fingers are in balance and are straight outward without effort just fine. But with the middle finger, it feels like picking up a dumbbell with that finger just to get it up there and keep it there. There's no way you can just 'work around' that.
It just ain't working right.

Lastly: Yes, if I just lay my hand on the table, don't engage any of the other fingers, and not spread the other fingers, then 'yes' I can raise the finger with pretty much full strength like that.
That is why I have been leaning toward a neuropathological root cause (but still keeping an open mind for other possibilities).

Originally Posted by anamnesis
Did any of the clinicians you've seen actually give a diagnosis or why they ruled things out? I'm just a bit surprised that you've run that gamut and none of them pursued dorsal interosseus nerve entrapment more.

I didn't want to bias any thought earlier, but I'll mention now. The first hand surgeon consult, with a surgeon who I have no problem with is experience, seemed intelligent, old as dirt and appeared to know his stuff.

HIS GENERAL ASSESSMENT: (Again, to be fair to him: He wasn't attempting to give a guaranteed certain diagnosis just by looking at the outside of the arm and performing a few palpations.)

After a good 30 or 40 minutes of history, and some exercises, etc. it was his belief that the cause might be a . . . stretched tendon (the extensor tendon).

?

He has a lot of years experience, so I can't 100% discount his assessment. But, I'm hard pressed to consummate that conclusion. Especially, considering that I've had no trauma to the fingers, hand wrist or arm to cause such a injury.

I mean, is it possible that over time that the tendon could have elongated itself - maybe possibly due to some sort of biophysiologic changes in the body (that's my theoretical explanation, that's not what he said)?? Well, theoretically I suppose anything is possible.

Now, in fairness me: I don't feel that he was truly too interested in my case. My primary physician sent me to him for the consult, and I get the sense that he kinda felt like "why are you coming to me for this?".
Now, in fairness to him: I do feel he took it seriously and gave his true professional opinion, and "he" was the one who did order the ultrasound for me (a few of months later).
Although, in fairness to me: "I" was the one who asked him for the ultrasound. hahahaha
I had sent him a letter, a laid out the medical justification for ordering an ultrasound. He agreed.


The other docs didn't bail on me, but for the most part all of the other possible diagnoses are still not definitively confirmable, and are all at the mercy of physical therapy - which is what we did (well, more so what "I" did).
If it's nerve entrapment, all can you do is PT... and see if it gets better. You still won't know for sure if that's what is was. (Unless you 'only' did exercises geared toward 'that' issue.)
If it's adhesions, all can you do is PT... and see if it gets better. You still won't know for sure if that's what is was. (Unless you 'only' did exercises geared toward 'that' issue.)
If it's carpal tunnel, all can you do is PT... and see if it gets better. You still won't know for sure if that's what is was. (Unless you 'only' did exercises geared toward 'that' issue.)
You get the idea.

If we had the ultrasound and saw lesions or carpal tunnel thickening (retinaculum), that would be different. But, nothing on the ultrsound or the EMG.

So, the likely outcome is that I'll do a complete PT and rehab program, I should be able to get it at least a little better, and will possibly never know exactly which of the things I did contributed most to fixing it.
Originally Posted by Jethro
Have you tried rest or have you been practicing all throughout this ordeal?

It was difficult to do so at first, but eventually I gave up on it altogether; so I've gone as long as 9 or 10 months without sitting down at the piano (and even then not for very long).

(Well, good news is that at least I can say that it hasn't really gotten any worse since the initial onset.)
Time to take up the violin.
Originally Posted by johnishere
Originally Posted by Jethro
Have you tried rest or have you been practicing all throughout this ordeal?

It was difficult to do so at first, but eventually I gave up on it altogether; so I've gone as long as 9 or 10 months without sitting down at the piano (and even then not for very long).

(Well, good news is that at least I can say that it hasn't really gotten any worse since the initial onset.)

Ok your issue is now officially driving me crazy. There IS answer to this but I don't think I have a clear picture of what you are experiencing though in my mind- though I thought I did.

I understand you are having a hard time lifting your right middle finger when all your fingers are extended (in a relaxed position) and laying on the keyboard. The R middle finger droops about 1/2 inch below the other fingers in this position such that you cannot raise the middle finger to hit the black keys and even when you are just playing the white keys the motion is twitchy moving from 4-3-2 or 2-3-4. (Now of course, if your middle finger is already drooping 1/2 inch below the other fingers even off the keyboard this motion is not to be smooth).

So- there are very few reasons this could be happening. The main ones to start with is this a musculoskeletal issue (muscle, tendon, joint capsule) or a nerve issue (signal not being sent to that middle finger) or there can be a physiological issue (such as OA, RA, history of stroke).
So I'm going to ask you several questions to try to clarify things for me- cause I really want to help you out and it pains me that a pianist who has played the piano for 37 years hasn't played for months due to this.

So first any background medical history would help (if you are comfortable to share) that may explain this such as: any history of osteoarthritis in the hand/fingers? any history of rheumatoid arthritis in the fingers? any history of stroke or ANY other neurological condition that you are aware of? Any circulation issues. Have you ever had a history of neck problems? Do you have neck pain now?


Are you on any medications?

Do you have any pain in that right hand?

Tell me how and when this deficit started. Was it suddenly? Did it happen over time? Did you experience pain when you first noticed it? Did have any numbness or tingling when it first appeared? Did you have accident involving that middle finger any time in the past when you were playing sports ie. was it ever badly sprained- even in your youth?

What bothers me the most is that I'm having a hard time understanding what you mean by having bulk strength but not fine motor control. By this do you mean you have strength in your wrist and fingers into extension but there is a lack of strength only in the middle finger?

To help me with this last question I'd like for you to do some manual muscle test on your wrist and each joint of your middle finger. I'm assuming you have full grip strength and that you are right handed? So, when you compare your left grip to your right grip they are about equal or maybe even the right hand being a little stronger? If this all yes then do this:

There are 3 joints in your middle finger, the MCP joint (metacarpophalangeal joint), the PIP (proximal interphalangeal joint), and DIP ( distal interphalangeal joint). All these words do is just tells me which is the knuckle, which is the next closest joint to the knuckle and which is the farthest from the knuckle (ie. distal). I need for you to isolate each one of these joints. But start with the wrist.

With your wrist in neutral (aligned with your forearm) Take your good hand and resist extension of the wrist of the right hand and then compare that test with the left hand. Do they feel about the same?

Now with your wrist in neutral take your good hand and resist motion at the MCP (knuckle) by resisting motion at segment of your finger just distal (towards the finger tip) of the knuckle joint and compare it to your L hand. Do they feel the same?

Finally test the farthest joint (DIP) in extension by resisting extension of the most distal joint in your right middle finger by resisting motion at the fingertip. Compare to the left does it feel the same?

Now check range of motion (AROM) Active range of motion. Can you make a full fist with the hand? When you open the hand with your wrist in neutral are all the fingers in alignment and all fingers fully extended?

Now check range of motion (PROM) passively. And check each finger (2-5) and compare to the left. So what I want to do is check each joint for flexion and extension (MCP, PIP, and DIP- the 3 joints in each finger starting with the knuckle (MCP)). So relax the right hand and with your good hand check the range of motion in each joint with the right hand and fingers always relaxed and take each joint through its range of motion all the way to the end and in each direction. At the end of each range do you feel any pain, any resistance, anything tight or not wanting to go all the way? Do you feel any restrictions in the joint itself- does it feel stiff?

Finally palpate that right middle finger starting from knuckle all the way to finger tip. Press hard everywhere is there any pain where you press?

If you can provide a video of how the right hand moves when its on the keyboard and off the keyboard that would be very helpful. Just open and close each finger independently and together as if you were mimicking a duck bill.

This would give me a clearer indication of what's going on and maybe (not promising) can give you a better advice. I am still leaning towards PIN as it seems to make the most sense, but some of the things you are describing don't make sense to me especially in regards to your individual finger muscle strength when its in certain positions.

But what I also want you to do is to seek out the best "CERTIFIED" hand therapist in your region and get their advice.



Originally Posted by johnishere
Originally Posted by anamnesis
Did any of the clinicians you've seen actually give a diagnosis or why they ruled things out? I'm just a bit surprised that you've run that gamut and none of them pursued dorsal interosseus nerve entrapment more.

I didn't want to bias any thought earlier, but I'll mention now. The first hand surgeon consult, with a surgeon who I have no problem with is experience, seemed intelligent, old as dirt and appeared to know his stuff.

HIS GENERAL ASSESSMENT: (Again, to be fair to him: He wasn't attempting to give a guaranteed certain diagnosis just by looking at the outside of the arm and performing a few palpations.)

After a good 30 or 40 minutes of history, and some exercises, etc. it was his belief that the cause might be a . . . stretched tendon (the extensor tendon).

It seems a good guess, and what is more important, it may be that the shortening of the tendon can fix your problem whatever the cause is. But certainly you need to consult with other specialists before making decision.
Would a compression sleeve help a stretched tendon if it wasn't too badly damaged?
A stretched tendon would make sense if it happened over time or if there was a previous history on injury but it seems a logical scenario but not necessarily in this case. That why it would be nice to know his strength in each joint.
Take a look at this:
https://en.wikipedia.org/wiki/Focal_dystonia

It seems to match your condition.
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