Preventing Injury: The Violinist as a Small-Muscle Athlete

January 13, 2021, 9:53 AM · Do you know a violinist who has suffered an overuse playing injury? The likely answer is yes. The unfortunate reality is that most players learn a lot about the high injury rate for musicians only once they themselves are dealing with it.

It’s time we put the music’s dirty little secret front and center in our conversations, because overuse injuries are almost entirely preventable. The data for an informed discussion is there - I myself learned just how pervasive the problem is when I applied for a grant for technology development as an intervention for musicians and justified the need with the help of many studies. I'm summarizing what I learned for this blog post. The most prevalent injuries are PRMD’s, which stands for playing-related musculoskeletal disorders. The research paints a grim picture:

Wait, what? This is unacceptable. There are six main contributors to injuries, which for musicians, happen gradually over time, as opposed to all of the sudden. We say “contributors” as opposed to “causes” because there are usually several factors in play when it comes to injuries. The six main contributors are:

  1. Genetics
  2. Asymmetrical positioning (for example a violinist is more asymmetrically positioned than a pianist)
  3. Faulty positioning & faulty technique
  4. Overuse (too much time on the instrument)
  5. Binge practicing (too much at once, or coming back from non-playing too quickly)
  6. Lack of sleep and other life habits (computers, painting)

For us violinists, it means we have control over four out of six -- everything but genetics and asymmetrical positioning.

The sleep data I reference is coming from the sports world, where sleep has been studied in much greater detail. Sports can teach us something. The table below displays the chances of suffering an injury within a season for high school athletes in relation to the average sleep hours per night.

Sleep not only keeps the body strong, but repairs minor damage overnight, it essentially continually resets the clock. Sleep also makes you perform better.

Let’s take a quick look at the main categories of physical overuse injuries:

  • Musculoskeletal - tendonitis, carpal tunnel, disc degeneration, low back pain, arthritis
  • Neurological - focal dystonia, thoracic outlet syndrome, nerve entrapment
  • Hearing damage - hearing loss, tinnitus, hyperacusis
  • Hearing damage deserves a blog post all on its own, so for now let's concentrate on the PRMDs only. Some of the overuse injuries interfere with our playing, while others affect the rest of our lives. I have considerable overuse damage in my neck, which rarely affects my playing, but the reversal of the neck curve is something that I feel every single day. The severe arthritis I have in my left thumb joint (from tuning) does impact my playing. Here is a picture of a normal neck (left) and mine (right):

    Solutions? There are some, but it takes discipline. We need to make everyone aware and promote alternatives to endless hours on the instrument. Here are what I’ve dubbed the @REST strategies for injury prevention -- you can remember them by the acronym @-R-E-S-T. Not only do these help prevent injuries, but every single one of the strategies can make you a better player, too:

    "@-R-E-S-T" - Strategies for Health and Artistic Excellence:

    @ = ALTERNATIVES TO ON-INSTRUMENT PRACTICE


    R = RECORD & RECOGNIZE
    E = EXERCISE
    S = SLEEP
    T = TIME

    Click here for a one-page handout of these strategies that can be tacked on bulletin boards and taped to mirrors.

    As a player, take it seriously and treat yourself as the small-muscle athlete that you are. Players feeling pain should take it seriously, rest, and remediate their set up and ergonomic approach to their instrument. Also take a look at all of life’s activities. It will make you healthier and a better violinist. If you are teaching, it starts with us. What we say and do matters. Treat your students like artist athletes and reference healthy habits constantly. Make students aware of the risks, and bench them if they are feeling pain. Pain is the warning sign for injuries in the making. Let’s promote a pain free culture early and often and forever.

    For more resources, including apps for recording and decibel monitoring as well as ear plug recommendations, visit https://www.practizma.com/resources.


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    Replies

    January 14, 2021 at 06:53 PM · A characteristically scholarly post from Prof. Klein.

    The computer is trashing my shoulder. The violin loosens it up for about an hour but then it feels even worse.

    I use the Etymotic ear plugs. They fit me well and they attenuate to a reasonable level. However, I will admit that it is harder to hear the flaws in my intonation. I sometimes replace the right-side one with something less attenuating.

    January 15, 2021 at 06:36 PM · Thanks, Paul! Yes, I agree the computer is by far the worst culprit for me too. Ideal set up is a big monitor that's significantly higher than the fingerboard. Since Covid I've just bee on my laptop and it's not good. Thinking about investing in a monitor. I wear cheap 11db earplug in the left only.

    January 16, 2021 at 05:42 PM · Thanks for this article! This is a topic that needs to be examined constantly. If any readers have not had a playing related injury yet it’s just a matter of time before you do. Prevention can not be understated. I am also relating to the past article “Shouldering the violin: my comeback from rotator cuff injury”. I have a similar situation with my right shoulder which has been diagnosed as arthritis caused by repetitive motion. It severely impedes my bowing capabilities. I’m very interested in hearing about anybody with these issues and how they dealt with it i.e. treatments , exercises . I have refused cortisone shots as they are known to further deteriorate tendons. I am currently being treated by a chiropractor and taking some natural joint support dietary supplements. Any similar experiences or thoughts on this matter are appreciated.

    January 16, 2021 at 11:22 PM · When I started up again after a 45 year layoff I played for about a year and developed such tendinitis pain in the left hand (my dominant hand) that I had to rest for 3 months. I kept asking my teacher why the instrument wasn't comfortable as it was when I was a child. No response.

    Time passed, new teacher, first lesson. The very first time we met he noticed in the very first minute that I had forgotten the basics of posture that I'd learned my first week as a child. I was not moving my elbow with the movement of the left hand across the fingerboard. I was stretching with the fingers and straining the tendons in my hand. Duh, Ann. Problem solved. I had similar problems with bowing and now 4 months later I am playing an hour a day with absolutely no discomfort. I'm following his advice to exaggerate the motion of the left elbow and it works great.

    January 18, 2021 at 07:54 PM · Thanks, Prof. S.K., for that important topic, that deserves repetition.

    I am also one of the majority with playing related physical problems; hearing loss, medical (juvenile onset rheumatoid arthritis), ergonomic (thoracic outlet syndrome). When I went to physical therapy, asked what the problem was, I said something like: "turn your left arm counter-clockwise until it stops, bring it in to 90 o, then shake it (vibrato) for hours, every day, for decades, and what do you think might happen?" At another session I brought the violin, played it with my shirt off. The therapist pointed at a spot between my spine and right scapula and said, "O.M.G., you use that muscle All the time!"

    We are not designed to play the violin, and the violin was not designed to be played by us. I am amused and suspicious whenever I hear that a player or teacher has a "natural" approach to this instrument.

    Over-training is a real problem. The ideal workout schedule is to alternate heavy and light days. This is because stressed muscles need one day to recover. The single strand, sub-microscopic protein molecules that connect the actin and myosin fibers need to be repaired or replaced. Working professional musicians and serious students do not have the luxury of arranging that alternate day strategy, but many of us can arrange one day per week(Mondays?) completely off. The sports medicine doctors and trainers working with expensive professional athletes have learned this a long time ago. The last people to learn this lesson are musicians and the military. They break soldiers all the time in basic training. L. Auer recommended 3-4 hours a day maximum for players intending to be soloists. I cringe when I hear about students doing more than that (binge-practicing) preparing for auditions and contests.

    Serious singers have learned to take care of the very small muscles of the vocal mechanism. A singer doing a lead solo opera role will not do a strenuous practice session a day before, the same day, and a day after the performance, just warm-ups.

    Damage to the tendons, ligaments, and synovial lining of the joints take Longer to heal than broken bones. The blood supply and repair cells are very low.

    Take a lot of short breaks. The blood supply will not be able to keep up with the oxygen and glucose demand of a continuously tensed muscle. Isometric exercise is fortunately out of fashion. A marathon runner "hitting the wall" is something different. That happens when the simple carbohydrate supply in the blood, liver, and small intestine is completely exhausted. The liver cannot process stored fat fast enough to supply the demand of the heart and brain. This is dangerous. Some runners die.

    A little bit about diet. We need a supply of complete, balanced, essential amino acids every day. The best source is animal protein (sorry vegans.) Fat has had a bad reputation because of cholesterol deposits in the arteries, but cholesterol is required for the electrical insulation of the nerves and the chemical base of all of our hormones.

    Minerals: four minerals are needed for the electrical signals from the nerves: Sodium, Potassium, Calcium, Magnesium. Americans don't need more sodium (salt), and we all have a calcium reserve in the bones. Many of us have a deficiency of Potassium and Magnesium, the best sources are from vegetables. Be careful about pill-form supplements. Calcium can neutralize stomach acid, Magnesium can cause diarrhea, and an over-dose of potassium can cause dangerous heart arhythmia.

    Hope that helps,

    JQ-(retired med lab tech)

    January 18, 2021 at 08:47 PM · Joel, excellent post. I, too, have multiple problems. There are almost always workarounds. An understanding teacher helps. We work with what we have.

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