Post-traumatic Range of Motion Loss in a Professional Pianist: A Multimodal Approach




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Pathological scarring is a fibroproliferative condition that occurs after abnormal tissue repair following a lesion or infection. Treatment is typically seen in post-operative or burn patients with common scarring distributions along the face, shoulders, and trunk. However, in the case of accidental, superficial injury to the hands of a musician, there exists a unique opportunity for treatment of post-traumatic scarring. For a professional musician, music is not just a career but a profound and inseparable part of their identity that is significantly threatened by what may appear as minor scarring. Pathogenesis of scarring is unclear and complex, involving disordered angiogenesis, inflammation, and tissue deposition. For this broad pathology, there are many therapy options based in pharmacology, pressure, immobilization, photoelectricity, radiation, cryotherapy, and surgical techniques. Of these, corticosteroid injections are frequently attempted because they are not only anti-inflammatory, but also repress transcription and fibroblastic factors while promoting extracellular matrix remodeling. These properties can directly improve scar volume and elasticity. Given the extensive array of treatment options and targets, adopting a multifaceted therapy approach is vital.

Case Presentation:

A 35 year old male musician with a past medical history of cervical stenosis at C3-C6 presented with a primary concern of decreased dexterity in his right hand, secondary to direct trauma sustained in a motor vehicle accident six months prior. He also experienced dull, burning pain across his right hand that was worse in the thenar area and exacerbated by use. As a musician he practiced up to 8 hours daily and thousands of hours yearly. He saw multiple physicians and surgeons who primarily focused on pain. He had been splinted since his injury, failed trials of high dose duloxetine and anti-inflammatories, received minimal therapy and received CMC and PIP corticosteroid injections, without relief. His ROM was functionally limited on exam, with 1-2 centimeters of difference upon right thumb opposition, flexion and extension as compared to his left. His neurologic exam was unremarkable. Ultrasound showed a slightly thickened edge of his palmar aponeurosis and 2.5 mg of Kenalog was injected into this fascial plane. Additional treatments included retraining of central pain sensitization, nitroglycerin patches, anti-inflammatory and methyl-based topicals, kinesiotaping, electroacupuncture, Feldenkrais education, and arranging regular occupational therapy, soft tissue manipulation, and psychosocial counseling. This comprehensive rehabilitation approach helped the patient regain hand dexterity and ROM that was lost secondary to prolonged immobilization and scarring, ultimately facilitating his goal of returning to his prior level of playing.


A multimodal treatment strategy and the use of corticosteroid injection in an atypical setting was significant to this case. Treatment of pathological scarring that occurs outside an operative or burn setting is less commonly seen or needed. The indication for this treatment strategy was decided with recognition that a centimeters level of change in ROM carried substantial meaning for this professional musician. His life was his art. As such, our approach acknowledged the profound physical and psychological impacts of his scarring and the value of comprehensive treatment and rehabilitation throughout this unique encounter.