Entrapment syndromes of the upper limb are common neuro-muscular-skeletal pathology in musician instrumentists. From this group of morbid entities, the most prevalent worldwide is carpal tunnel syndrome closely followed by the cubital tunnel syndrome and de Quervain stenosing tenosynovitis. Due to their distinctive etiopathogenic correlation with exposure to specific occupational factors linked to instrument interpretation and professional environment, these diseases raise a medical challenge and constitute a socioeconomic and professional burden with legal branchings and implications for individuals and society. These syndromes develop isolated or more often in various associations with each other in a clinical pattern that has been described under the model of “double crush” syndrome by Upton and McComas. From its inception in 1973 until the present time, this clinical model has been a point of interesting debate between various specialists worldwide. This model underlines an already lesioned neuron’s susceptibility and vulnerability for further neural damage at a different level from the initial lesion. The sophisticated clinical presentation of this “double or multiple crush” syndrome is due not only to overlapping symptomatology from each contributing neuro-muscular-skeletal pathology or lesional site but also to other local or systemic conditions such as trauma, diabetes, osteoarthritis, thyroid disease, obesity, etc. The occupational factors such as repetitive movements, strain and overload, vibrations, ergonomics, and others all contribute to the creation and progression of the morbid process. We cannot overstate the implications of understanding these complex relations and interdependencies between the factors mentioned above as they are essential not only for the diagnosis of these neuropathies but also for the treatment, rehabilitation, and occupational reinsertion of the patients. The studies support the fact that both lesional sites need to be medically addressed for an optimal outcome and resolution. We present the case of a female violinist with bilateral multiple neuro-muscular-skeletal pathologies of the upper limb treated previously invasively and conservatively over several years by various specialists without a satisfactory clinical resolution of the symptomatology or any professional and legal measures taken.
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1. Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973;2:359–62.
2. Joseph M. Bellapianta et al.: Chapter 21 - HAND PAIN, Current Therapy in Pain, 2009, Pages 156-167, ISBN 9781416048367.
3. G.D. Lister, R.B. Belsole, H.E. Kleinert: The radial tunnel syndrome, The Journal of Hand Surgery, Volume 4, Issue 1, 1979, Pages 52-59.
4. YC Loh et al.: A new clinical test for radial tunnel syndrome—the Rule-of-Nine test: A cadaveric study, Journal of Orthopaedic Surgery 2004;12(1):83–86
5. L.B. Dahlin et al.: The neuron and its response to peripheral nerve compression, Journal of Hand Surgery (British Volume, 1990) 1SB: 5-10
6. L.C. Hurst, D. Weissberg, R.E. Carroll: The relationship of the double crush to carpal tunnel syndrome (an analysis of 1,000 cases of carpal tunnel syndrome), J. Hand Surg. [Br], 10 (1985), pp. 202-204
7. Brent S Russell: Carpal tunnel syndrome and the “double crush” hypothesis: a review and implications for chiropractic, Chiropractic & Osteopathy 2008, 16:2
9. Galarza M, Gazzeri R, Gazzeri G, Zuccarello M, Taha J. Cubital tunnel surgery in patients with cervical radiculopathy: double crush syndrome?. Neurosurg Rev. 2009; 32(4) :471-478.
10. H. Baba et al: Changes in peripheral nerve fibres distal to a constriction, Journal of the Neurological Sciences, 1982, 54:197-208
11. Koichi Nemoto et al.: An experimental study on the “double crush” hypothesis, The Journal of HAND SURGERY, vol. 12A, No. 4 July 1987, pg.552-559
12. A.O. NARAKAS: The role of thoracic outlet syndrome in the double crush syndrome, Ann Hand Surg, 1990, 9, n° 5, 331-340.
13. Kwon HK, Hwang M, Yoon DW. Frequency and severity of carpal tunnel syndrome according to level of cervical radiculopathy: double crush syndrome?. Clin Neurophysiol. 2006;117(6):1256-1259.
14. Chakravarthy Marx, S., Kumar, P., Dhalapathy, S. et al. Distribution of sympathetic fiber areas of radial nerve in the forearm: an immunohistochemical study in cadavers. Surg Radiol Anat 32, 865–871.
15. Kane et al.: Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome. J Hand Surg Am. 2016;41(12):1171-1175.
16. Gautam J. Desai DO et al.: Chapter 70 - Carpal Tunnel Syndrome, Integrative Medicine (Fourth Edition), Elsevier, 2018, Pages 697-706. e2, ISBN 9780323358682
17. Joseph E. Pizzorno et al.:15 - Carpal tunnel syndrome, The Clinician’s Handbook of Natural Medicine (Third Edition), Churchill Livingstone, 2016, Pages 180-187, ISBN 9780702055140
18. Sotereanos DG, Varitimidis SE, Giannakopoulos PN, Westkaemper JG. Results of surgical treatment for radial tunnel syndrome. J Hand Surg Am. 1999;24(3):566-570.
19. David C. Preston, Barbara E. Shapiro: David C. Preston, Barbara E. Shapiro: 29 - Radiculopathy Pages 448-467, 30 - Brachial Plexopathy, Pages 468-486, 31 - Proximal Neuropathies of the Shoulder and Arm, Pages 487-500, Electromyography and Neuromuscular Disorders 2013, ISBN 978-1-4557-2672-1
20. Mary G. Hochman MD: II/14 Entrapment Syndromes Pages 239-263, Imaging of Arthritis and Metabolic Bone Disease, 2009, ISBN 9780323041775
21. Geraldo Fabiano de Souza Moraes et al.: Musculoskeletal disorders in professional violinists and violists. Systematic review, Acta Ortop Bras. 2012;20(1): 43-7
22. Richard A. Hoppmann and Nichols A. Patrone: A review of musculoskeletal problems in instrumental muscians. Seminars in Arthritis and Rheumatism, Vol.19, No.2 (October), 1988, pp. 117-126
23. Peter Bragge, Andrea Bialocerkowski, Joan McMeeken, A systematic review of prevalence and risk factors associated with playing-related musculoskeletal disorders in pianists, Occupational Medicine, Volume 56, Issue 1, January 2006, Pages 28–38,
24. Zaza C. Playing-related musculoskeletal disorders in musicians: a systematic review of incidence and prevalence. CMAJ. 1998;158(8):1019-1025.
25. John Chong et al: Occupational Health Problems of Muscians. Can Fam Physician 1989;35:2341-2348
26. V.A.E. Baadjou et al.: Systematic review: risk factors for musculoskeletal disorders in musicians. Occupational Medicine 2016;66:614–622
27. Patricia Blanco-Pineiro et al.: Musicians, postural quality and musculoskeletal health: A literature’s review. Journal of Bodywork & Movement Therapies (2017) 21, 157e172
28. Colin E. Gough : A violin shell model: Vibrational modes and acoustics. Journal.Acoust.Soc.Am.137(3), March2015, pp. 1210-1225