From Jennifer Sersaw
Posted September 26, 2006 at 02:34 PM
I have heard of rotator cuff injuries in violinists most recently in the Whole Notes Magazine (Toronto based) where there was an add for a string group where one of its members was off because of rotator cuff surgery. I will try and find the musicians name and get back to you. All the best.
That physician would understand that shoulder pain often affects the neck as well. The symptoms you are describing lead me to believe that there is some amount of cervical involvement. After all, violinists spend so much time with their heads to the left.
A licensed massage therapist can work wonders.
There is also a book out I have seen called, "Playing less hurt". There may be some references and contact information that might aid you in the book.
I know that your issue seem more complicated but as a new student to violin and a member of the healthcare profession I am truly surprised that there isn't more emphasis put on appropriate set up.
I was surprised to find that there are few resources to get assistance in determining the best shoulder rest, the best chin rest etc, for your specific physical characteristics. It seems to be that "whatever the teacher" uses is the predominant theme here.
Being a particular person I am on my 4th chin rest (waiting for the 5th to be shipped from the UK) and 3rd shoulder rest in the quest for the best "fit" so that I am comfortable playing for long periods of time. I have analysed my problems based on what little information I can find on the web and my body characteristics. This has been very educational but I would have gladly paid for an assessment and some set-up expertise from a professional.
I have come to beleive that a lot of the damage is done in childhood because people don't take the set-up seriously for kids. My 6 year old has gone through 3 chin rests (not many options for children making it all the more difficult) for me to find one that works. I had to go to 3 different violin shops to find one that would stradle the tailpiece that would fit a 1/8th and was high enough for her long neck. The difference is amazing. She does not complain at all about pain anymore, plays longer, is focused, her sound it infinitely better and her teacher told me last week she loved her set up.
So if you were playing for many years with a less than optimum set up through childhood and adolescence when your body was still growing it is no wonder to me that you have such a serious problem.
I hope you can find a solution and return to playing.
All the best,
This is why masters like Ricci (studied with Piastro), Rosand, Milstein, Elman, and many other Auer violinists continued to concertize at a very high level well into their 70s without pain.
Anyway, during the course of ortho treatment in preparation for surgery, I came across a variety of alternative therapies which I found quite effective: cranial-sacral therapy, MLD therapy (manual lymph drainage - for swelling), homeopathy, acupuncture (Japanese style) and Bowen therapy. I also had regular massage and chiropractic care, but I've stopped going to these, and now only see the acupuncturist 3x a year (for tuneups) and have occasional thai yoga masssage (I'm also a thai practitioner and do regular yoga practice). My posture is better than it's ever been.
A friend of mine (not a violinist) had a rotator cuff injury and went to see our acupuncturist (who also does Bowen) - with one treatment this problem was resolved and she hasn't had to go back. Apparently he also corrected another problem - one leg was longer than the other. I've had some Bowen therapy along with acupuncture, and I've been pleased with the outcome.
I just thought I would mention this therapy as I haven't seen it discussed here. The cost of a one hour treatment is C$75, and quite often a single treatment is enough to correct the problem.
In other cases, the muscles under the scapula have shrunk (atrophied) from weakness or inactivity. The scapula bone then rides more closely to the rib cage. This means the scapula bumps or rubs on the rib bones during movement.
Changes in the alignment or contour of the bones of the scapulothoracic joint can also cause snapping scapula.(He thinks it may be a bit of this problem since a bone spur developed) When a fractured rib or scapula isn't lined up just right, it can cause a bumpy ridge that produces the characteristic grind or snap as the scapula moves over the chest wall.
He believes that somehow when I received the initial injury back in 1998 the actual injury was overlooked. It caused a ridge to develop and a bone spur. Unfortunately, because it has gone untreated and undiagnosed for so long, it has had time to get worse instead of better.
Snapping scapula is actually a rare condition and not that many people know about it. It also has an affect on the muscles in the surrounding area and is very close to a nerve (imagine that) that goes up into the back of the head (where I get my headaches).
There are three treatments for snapping scapula. Anti-inflammatory medications, physical therapy, and surgical correction. He is 95% sure that the first, anti-inflammatory medications is not going to solve the problem since a lot of times I really don't have inflammation. Snapping scapula causes a hardening of the muscles in the surrounding area which is why I always feel like I am tense in the shoulder, even when I am not. You can actually hear and feel the snapping whenever I move my shoulder, which is why I knew it had to be something. So, we are going with treatment number 2 for now. I am being sent to a very specific type of orthopaedic physical therapist who specializes in these kind of conditions. She is the only one in our area who knows how to work with this condition. We are hoping that we can retrain the muscles to work around the bone spur and everything else related to the problem and get the muscles to stop hardening, but since it has been existent for so long and had a lot of time to get worse instead of better, we have a tough road ahead of us. We are giving it four weeks to see if we can get any improvement, then we will go back and discuss what to do after that.
Personally, I want to do the physical therapy first, but I am not afraid of surgery. I know all of the risks involved and know about weakening of the shoulder muscles etc; however, I am still young so healing and strenghthening of muscles will not be as difficult for me as it would be for some others. I am so tired and ready for the headaches to stop, that I am open to something such as surgery if it is my last and only option. For now, I will be doing the physical therapy and will go from there. Both the doctor and physical therapist know I am a violinist so everything we do will be keeping that in consideration. If anyone knows any violinist who has ever had this problem, please let me know.
not trying to sound inconsiderate, but since it has been a long time, the chance of complete recovery is rather slim. you have a chronic condition, snapping scapula or not which is a vague complex of symtoms as a label.
also, not trying to probe, but when you do visit you next doctor, you may want to clearly tell him/her the specific nature of that accident in which you injured your "shoulder". how? from a height? high speed/low speed? what symptoms or associated symptoms you can remember then, etc. we do not need to know here but that is very important for your doctors to establish a background on the soft tissue pain syndrome that is established.
assuming imaging studies have not revealed anything other than the suggested clinical diagnosis of soft tissue involvement, you have been going through the right approach for rehab but you may have not have been lucky enough to find the right environment to heal.
anything that puts physical/mental/emotional stress on you may manifest itself through your shoulder region and possibly with radiating pain into your head region. it is very challenging to rid of all stresses in one's life and we have to deal with the hand we are dealt with the best we can, right?
the current literature has 2 recommendations that are almost consistently agreed upon. 1. increase physical conditioning. 2. sparing usage of elavil/amytriptline, at very low dosage, not as an antidepressant, but as a chronic pain antigonist. there is evidence the medicine may help relax muscle-muscle junction.
now, in terms of exercises, do what you can and do not overdo it to the point that you may add new injuries to the old ones, in the name of getting the region stronger. use common sense. if that area is sore, lay off, and simply increase your conditioning by fast walk/slow jog. this is not my idea, but research after research indicates that when they survey chronic pain patients retrospectively, those who do more exercises experience less pain.
overall, your acupucturists/massage therapists/physical therapists/neurologists do not know what you really go through each day, as a violinist, a wife, a mother, a person in agony. your condition may be such that because of the location of the problems, the smartest physician can pinpoint correctly but may not have a ready solution for it. therapy? sure. trigger point injection? may be. surgery? hell no. medication? well, those that will really knock the pain out will also knock you out.
if i were you, i would depend less on what the doctors say on diagnosis at this juncture because you have heard it many times. it is going to be scupular something. migraine something.
try swimming, long walks, practice and play violin with moderation. do things in life because you want to, that you find enjoyable. accept the pain as part of you. ACCEPT IT. tell the pain you are going to respect it and work with it. the pain is not in your head, but,imo, your mind has a lot to do with how successful you will be in containing it to a tolerable degree.
wish you the best of luck in creating an environment to heal better and look at the bright side of things not for fun but for quality of life.
I also take amitryptyline, in a very low dose (10 mg at night) for sleep disorder, the med that al ku mentioned. It's widely prescribed for people that have jaw clenching problems since it can act as a muscle relaxant. It also might help with this problem.
I'm not a fan of surgery or meds, they are a last resort in my books. I do wish you relief from your suffering.
however discouraging it may sound, soft tissue pain lasting more than 6 month duration has a slim chance for complete recovery. complete recovery means 100%; that does not mean people cannot reach 90%. we are all pathological one way or another after the age of 30 something when the body starts to show signs of wear and tear. but we suck it in and carry on.
however, in some cases, the pain is just too lasting and uncomfortable to bear, to the point it is interfering with daily activities.
and we want answers, why, what is causing the pain? sometimes, it is an easier route to take when the xray shows a fracture and it heals in several months unremarkably. when xray and mri are not revealing, however, everything is put in a basket called soft tissue injury. the physician's clinical judgement comes into play. he "thinks" it is a scapular dysfunction based on his experience (or lack of) or deduction. however, the arrival of a diagnosis, even a correct one, does not necessarily mean a guarantee in successful rehab outcome with soft tissue cases. every scapular dysfunction is different and every affected person is different.
but the common theme is to increase overall physical conditioning for more optimal function. swimming/aquatic exercise is an excellent exercise for the scapular region against gentle resistance. exertion using weight against specific muscles around scapular before they are sufficiently built up may not be a great idea. as another poster has related, elavil may also be of help since it improves quality of sleep for people with chronic pain which may promote better healing of soft tissue during deeper, more restorative sleep. anatomical studies have shown that in patients with chronic pain there are often trigger points which when dissected and put under microscope show area of ischemia, meaning some soft tissue does not get good blood supply. why do people with heart attack have pain in the chest? because part of the heart muscle does not get blood when circulation is blocked.
the pain signal is received in the brain. if you prick your finger once, you say ouch. how does the brain react if the finger is pricked continuously for more than 6 months? the brain adapts. there is a phenom called phantom pain in which a person loses a limb but still feels the pain of the lost limb long after.
the mind-body connection in soft tissue injury has long been observed but still poorly understood. the stigma is that the affected are crazy, that the problem is in their heads. not true and in fact that perception make things worse when they feel misunderstood and nobody can do anything about it.
that is why i call for some effort in establishing a better healing environment in which in face of facts,known findings and uncertainties people are supportive and understanding. lets not talk in terms of cure but function and symptom improvement. unfortunately not many health care providers are great healers these days when they are rushed to cut cost and save time. the last time i saw somebody (not a psychiatrist i swear, not yet) he did not even bother to sit down, so how was i going to be comfortble telling my story when i thought he was about to sprint out of the door in any seconds?
soft tissue injury is a huge social problem. many people with unremarkble imaging studies have real pain, under recognized, wrongly or poorly diagnosed. on top of that, poorly treated. often they are even labelled as fraud in the medicolegal system.
in summary, as much as i hesitate to state the general prognosis, i want to draw the distinction between realistic outcome and false hope because i believe the latter may cause more grief in time. good luck and good day.
Violinist.com Editor Laurie Niles is in New York to cover the biennial event at The Juilliard School, including classes by Brian Lewis and Sarah Chang.
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