We compare the clinical characteristics of a large US musician cohort with musician’s focal dystonia (MFD) to musicians with non-dystonic ulnar nerve entrapment (UNE) and the entire musician cohort.

MFD, including focal hand dystonia (MFHD) and embouchure dystonia (ED), affects up to 2% of professional musicians, causing substantial morbidity. Peripheral nerve entrapment may play an etiological role. UNE at the elbow is impactful, given its key role innervating intrinsic hand muscles required for fine finger coordination.

A 40-year experience of MFD was analyzed by reviewing records of all patients attending a specialist performing arts clinic (1984-2015), with additional MFD patients included up to 2025. There were 2707 musician patients, including 290 consecutive MFD cases, 262 MFHD (one combined with ED), and 28 isolated ED. MFHD was compared to non-dystonic UNE (n=531).

In MFHD, the most common pattern was ring/little finger (D4/5) flexion. Of MFHD with UNE (n=80), 95% were ipsilateral. Dystonic D4/5 flexion (n=88) was highly prevalent (65.8%) in ipsilateral UNE; D2-5/D1-5 dystonic flexion (n=17) was more common in ipsilateral carpal tunnel syndrome. 28 MFHD with ipsilateral UNE underwent surgical ulnar decompression: 89.3% had UNE symptom improvement, 50% had dystonic improvement. Only 38.2% of MFHD remained task-specific at follow-up. Resolution of MFHD occurred after motor retraining in 5 patients and non-surgical treatment of UNE in one patient. Predictors of MFHD vs. non-dystonic UNE included male sex, professional musician, increased practice pre-onset, pre-morbid depression, a new instrument, new teacher/technique, and trauma/surgery (p<0.0001). Predictors of worse outcome in MFHD included being a non-professional musician, non-task-specific dystonia, a family history of dystonia, and dystonic involvement of ≥3 fingers (p<0.006).

Dystonic flexion of D4-5 is associated with ipsilateral UNE, suggesting that UNE plays a role in the pathophysiology of focal dystonia. In MFHD with ipsilateral UNE, surgical and rarely non-surgical treatment may improve dystonia.