Overuse Injury in Musicians
David J. Sternbach, Director
Center for Arts and Wellness
College of Visual and Performing Arts
George Mason University
Overuse injury refers to any type of breakdown of tissues
(muscle, tendon, ligament)
- Loss of range of motion
- Loss of endurance
- Loss of fine motor control
- anxiety about potential for relief and for full recovery
- questions about continued long-term ability to perform at required
- loss of connection with music performance as a primary expressive
- potential loss of status, role, income
- if sufficiently severe, loss of career, challenge of learning a new
means of livelihood
The term includes injury:
- resulting from prolonged repetitive movements
- resulting from static loading or stationary load bearing
Example of injury from static loading: a bass trombonist fulfills
several conditions for overuse injury from continuous static loading.
FACTORS CONTRIBUTING TO OVERUSE INJURY:
Variations in human physiology; size shape. Potential for poor fit between
player and instrument.
Variable genetic disposition in terms of potential for achieving levels
of coordination and quickness of reflexes that musical performance demands.
Potential for weakness or predisposition to injury in particular areas
of physiology; vulnerability is a mix of factors, with individual variations
in individual levels and potentials of endurance, strength, and general
It has been remarked that in the Olympic competitions we see roughly
15% of all possible body types. There is a ruthless self-selection process
in sports at that level. But although musicians must perform at standards
close to those demanded of Olympic competitors, far more varieties of
physiological types perform on, and compete on, the same instruments.
One problem is that most instruments come as one-size-fits-all, particularly
for the winds, which means that some physical types are at a disadvantage
in their efforts to fit themselves comfortably to any particular instrument;
lack of a “natural” fit can interfere with a musicians’
ability to perform to their highest potential.
String teachers help beginners starting out on instruments sized appropriately
to the student’s growth and age. One observer has remarked that
beginning flute students would do well to be given smaller, lighter Eb
flutes. There maybe value in bringing influence to bear on manufacturers
to introduce smaller-scaled beginner’s wind instruments, and value
in exploring where customizing instruments to suit individual players
may help create better player-instrument fit.
FACTORS CONTRIBUTING TO OVERUSE INJURY; EXTRINSIC
Seat problems; poor fit, poor ergonomic design Crowding in seating
arrangements in ensembles leading to distortions of posture See also,
Dr. Robert Holt’s list of occupational stressors.
- Environmental; extremes of heat or cold, changes in humidity, issues
of air quality.
- Change in repertoire: tackling a work that places new demands physically
- Change in teacher
- Change in equipment
- Increased preparation and/or performance pressure-audition, school
juries, solos, etc.
- Basic flaws in technical approach
- Postural errors
- Excessive tensions in the body and in the mind
OF INJURY LEVELS
Grade I: pain occurs at the site of overuse only. Pain
is modest and disappears after practicing or performing is finished. Adequate
rest periods between effort, modest heat therapy, stretching, massage
and be effective.
Grade II: pain at multiple sites, pain is more severe.
No interference with normal Activities of Daily Living (ADL). Icing, rest,
massage, anti-inflammatories, appropriate compensatory stretching, and
relaxation skills are effective and relaxation skills are effective and
useful, and may alleviate symptoms.
Grade III: Pain exists at multiple sites, pain persists
after playing. Some pain accompanying normal ADL. May have loss of facility,
some weakness in immediate and associated areas. Primary level of interventions
is no longer ineffective (cooling, massage, rest periods).
Grade IV: same as Grade III but all Activities of Daily
Life are accompanied by pain, and there is impairment of functioning.
Grade V: loss of capacity to use affected area is secondary
to disabling pain. The injured individual cannot use that part of the
body when making music or for any other activity.
Grades III, IV, V require consultation with performing
arts medicine specialists.
LOCUS OF PAIN
These are statistical breakdowns of the most common locations for pain
- Hand and wrist 41%
- Forearm 11%
- Elbow area 10%
- Shoulder 35%
- Scapular area 7%
- Neck 38%
- Thoracic spine 8%
- Lumbar spine 26%
- TMJ 1%
* (These statistic’s from Norris, R., 1987,and others are primarily
drawn from populations of string players and pianists. Little data were
being collected at the time of this and other summaries of studies on
incidence of embouchure problems in wind players.)
SPECIFICS ON PRINCIPLES OF REHABILITATION
For grades I & II:
- Modification of technique and/or instrument if appropriate
- Reduction, relief of static load where possible
- Graduated return, or increase in playing with frequent rest
- Warm up entire body, as well as injured part prior to playing. Gradual
cool down afterwards.
- Anti-inflammatories; helpful in acute overuse injury, less so in chronic
- Biofeedback for general stress reduction and relaxation as well to
correct excessive muscle tension in specific muscle groups.
- Stress reduction training
For Grades II, IV and V
- Same as above but may require more extensive rest period away from
instrument while maintaining muscle tone in activities that do not exacerbate
- In all cases, work hardening is a principle that advocates graduated
return to a full schedule of practicing and performing over time. This
is intended to satisfy two objectives. First, to accommodate muscles
moving back to the former levels of challenge and secondly, to provide
a monitoring period to observe whether any recurrence of problems occurs,
before arriving at the full load levels of demand that could re-damage
PRINCIPLES OF PREVENTION
- Education as to causes of overuse injuries
- Enhanced awareness of early signals of potential overuse injuries
- General overall physical conditioning to increase stamina and strength
- Postural and movement re-education (Yoga, Feldenkrais, Alexander).
- Stress management, relaxation and meditation training to lower overall
levels of excessive psychological and physiological arousal levels.
- Systematic balancing of effort and recovery; i.e., practice and performance
- Stretching routines before, during, and after practice and performance
- Customized physical exercises specific to particular instrument and
- Modification where possible of instrument, accessories, and seating.
- Identification and relief of environmental hazards
- Develop a relationship with qualified health professionals in Arts
- Performance Psychology as resources for periodic checks to prevent
- Education in communication skills to reduce the potential impact of
- Finally, as a general principle, development of a long term commitment
to establishing and maintaining a balance between investment of self
in work, and in the maintenance of one's personal life in all dimensions.