Shoulder impingement-need encouragement

January 28, 2011 at 07:52 PM ·

I've been suffering from impingement syndrome since the middle of November and haven't been playing since then. This is very hard for me, because I am working on getting my Master's degree. I  finally got the doctors to refer me to Physical Therapy at the beginning of January. I started that two weeks ago. We've been working on posture and some isometric stretch band exercises and icing. I'll keep this updated as I go along. I'm feeling very down-hearted because this has been going on for a while and I'm feeling desperate. Just need a little encouragement and prayers, if you're a praying type of person. Thanks!

Replies (29)

January 28, 2011 at 08:00 PM ·

Sorry, I'm an atheist.

But I sympathise, and wonder what caused this? Bad teaching, bad technique, bad usage?

January 29, 2011 at 04:08 AM ·

I think mostly bad posture not only while playing the violin, but also while typing papers and doing stuff at work. I currently work in a music office/library where I'm often putting large amounts of music on shelves. I'm not sure this is even a violin related injury. It could be the cumulative effect of many things, including working a summer job where I do a lot of manual labor. I also ride horses. Perhaps my shoulders just aren't strong enough. I'm a very lean person with delicate, very sloping shoulders. It could be any number of these things. The straw that broke the camel's back was sleeping on my side and pushing myself out of bed one morning and SNAP! So I'm trying to redo everything about how I go about my day. How I sleep, how I get dressed, how I sit while I eat, how long I do homework on the computer, etc.

I went to physical therapy today and they said I could start playing a little bit as long as I keep my right arm low. That basically means I can play on the E string. Maybe the A string. Upper half of the bow. In a couple days after my shoulder calms down from electric stimulation, I'll start practicing scales for very short amounts of time.

January 29, 2011 at 05:12 AM ·

If it is your right shoulder, I can totally sympathize as I've been struggling with the same sort of thing - sheer pain shooting down from the shoulder to the pinky and ring finger.  After taking time off from the my CO to figure this out and spending much time in front of the mirror, I've narrowed down what could be causing it - half music related and half day job at the computer related. 

For work, I got a keyboard tray so that I do not need to raise my shoulders up around my ears while working.  I do alot of mouse work so my right shoulder & hand get the brunt of the tension. 

For viola playing, I've been meddling around with my setup again to correct the tilt of my head from being towards the right and raising my right shoulder which is the primary source of tension.  I think I finally found a shoulder rest that is low enough on the left side (the Augustin Diamond) with comfortable right side stability.  Combining that with padding on the chin rest to give right side support & lift seems to be doing the trick so far. 

Maybe an AT instructor could help...

 

January 29, 2011 at 05:57 AM ·

Have you had an MRI yet? That could tell a lot.

January 29, 2011 at 07:21 AM ·

I second the recommendation to look into Alexander Technique.  The American Society for the Alexander Technique (AmSAT for short) is here:  www.amsatonline.org/ .  It can give you a lot of help with simply being aware of how you are using your body during any given activity, and many teachers are accustomed to working with musicians & other performing artists.

I know hope can be hard to come by -- but you can make it!

 

January 29, 2011 at 08:06 AM ·

Mendy

The viola is not an instrument that is user friendly, and I would suggest in all seriousness that you either get a small 15" viola - or change to playing the violin.

 

January 29, 2011 at 12:34 PM ·

I know exactly what you are going through. I have had this problem off and off for years. I've done everything. I even stopped playing for 6 months, an eternity. But, the last time it got so bad I dropped my bow during rehearsal. I couldn't lift my arm.

So, I went to see a Specialist that works only with musiciens. She is a physcial therapist that works on your position and posture, and does massage. She also had a Luthier come in and measure me and my violin. Here's a few things I found out:

1) My violin was too long for me. A "standard" size violin, 4/4, is standardized for men, not women. On top of this, my violin was even a tad too long for a standard size 4/4. 

2) My posture was very bad. I was playing the violin from my shoulders. My body was static and my arms were waggling about from the shoulders. No wonder they hurt.

I spent months with her and my violin working on relaxing, shoulder position, head position (very important), body position, arm position, the position of my shoulder rest, the height of my chin rest, etc etc, seated and standing. Here's a crazy thing. She made me realize I could play using my shoulder blades. I did a lot of work on getting in touch with my shoulder blades!! The result was I was playing better and without meds and after having had very little massage, I had no pain at all. Plus, I was playing more than I used to because it didnt hurt. Now I pay close attention to the position of my head and  shoulders and hips. Instead of sitting in a chair when I practice, I use a stool so that I am halfway between sitting and standing. That seems to help with my posture very much. Good luck!

January 29, 2011 at 01:47 PM ·

I spend a lot of time in front of a computer and have optimized the ergonomics of my computer setup.  One thing that i really love is this Morency rest.  It allows me to rest my elbows and completely relax my shoulders while typing.  I also use a Microsoft natural keyboard.  Because it is curved in the middle, it allows typing with the wrists straight, rather then cocked which takes the strain off the fingers, wrists, and forearms.

@Jenny, I really hope you figure it out.  Injuries are a bummer.  I am currently struggling with achy fingertips and it has already been 6 months and still haven't figured out a good solution. 

January 29, 2011 at 01:48 PM ·

 I agree with Bruce--try Alexander Technique!  Buri posted several blogs about AT in the last years.  You might want to read them, too.  I just started, after years of pain playing viola (and I'm guessing that I'm  a LOT older than you) but even three lessons have changed my whole comfort level, as well as my awareness of how what I do affects my body.  I want to make AT progress faster, but that's not how it works...and it DOES work.  I'm driving 125 miles round trip for my lessons--it's that important, and it's that good.

Pain is your body saying something is wrong.  And while I agree the viola is LESS user-friendly than the violin, it is not necessary to be in pain to play one.  You need to make sure your teacher isn't making you play it like a violin--since it isn't one, you can't, not successfully, but you can play it pain-free with care about posture and set-up.  

I wish you a good outcome.

January 29, 2011 at 02:09 PM ·

Viola players are always in pain when they play - it's the sound!! (wink).

January 29, 2011 at 03:07 PM ·

 hello jenny,,,not sure where you got the dx of impingement syndrome.  since you are in mn, consider getting second opinions, such as consulting with some specialists in mayo clinic as a start.  

often the body build of a person has quite a bit to do with how much stress one can take in the shoulder area. for instance, studies have shown that people with sloppy shoulders are associated with more impingement problems.  some people are built ( born) with internal structures that make impingement more likely.  for instance, there is a piece of bony process inside the shoulder joint that is more rounded in some people but more protruded in others.  people with the protruded type tend to impinge the rotator cuff tendon more readily with overhead activities, such as playing d and g strings.   last month i yanked a piece of luggage off the conveyor belt in the airport,,,still paying for it.  since i am no spring chicken anymore, the healing time will be long,,,probably forever knowing my luck:)

proper therapy can change things for the better. strengthen the musculature around the shoulder joint so that the stronger ones can help compensate for the weaker ones, and the resultant shoulder action will be more balanced, so the rotator cuff glides more smoothly.  this type of therapy must be done very carefully,,,under the supervision of experienced sports trainers who work closely with a physician.  there are many out there who are gone-ho types and can make things worse, because they don't know when to push and when to back off.   it is as bad to push you when not indicated as not push you when indicated.

unfortunately, for some people, therapy can only do so much.  this is a tricky time.   you may need the help of those clinicians with the best experiences dealing with this type of decision making: to continue therapy or surgery.   will conservative management eventually lead to more wear and tear on the tendon, esp for those with a compulsion to play violin at olympics level?  is it worth the risk to operate and round off the sharp edges and clear up the area?   never an easy answer.

keep an open mind,,,consult with the better ones and take it easy with violin playing because chronic pain management is more important than violin playing.

is not playing violin for some time easily acceptable?  most certainly not.  but what if you have to?  this is often imo the true test of a person's resolve:  how to take hard news on something you love and how to convert adversity into positive thinking and action as soon as you are ready.

good luck.  i just summon all asian gods and goddesses to beam the power your way:)

Ommmmmmm...

January 29, 2011 at 03:26 PM ·

The second violin Karoly Schranz in the Takacs quartet had this very problem and had surgery last year in about March. He was back playing by about September and as far as I know he is fine.

Heard them live less than a week ago and he seemed as lively as ever!

January 29, 2011 at 07:15 PM ·

Thanks for all the great advice! I have been thinking about doing AT. There's a teacher somewhere in Springfield. I know that AT does wonderful things and I'm kind of kicking myself for not continuing with lessons. I took one lesson right before a concert. Usually I have a lot of stiffness after long rehearsals and concerts, but after that particular concert I felt wonderful.

A few changes I have made over the past 4 months is setting up my laptop on a stand and using a USB keyboard and mouse. I put some extra back supports on my desk chair. I put an app on my computer that reminds me to take a 5-minute break every 25 minutes. When I work in the music library, I stand on a chair to reach stuff on the top shelf.

As for physical therapy, I'll let you in on what I've learned so far. The basic protocol is oxygen, protect, strengthen. I ice my shoulder twice a day. Ice makes your body send blood to the cold area to keep it from freezing. Blood brings oxygen to the affected area. If you need to ice something, don't use the gel packs. They are not water and may  be colder than water. Therefore, they may do more damage than good. Your body is mostly water, so using real ice surrounded by water is best. It is best to use a large latex ice bag (unless, of course, you're allergic to latex). It's best to fill the ice bag with very small pieces of ice. Large cubes will not work. Then fill the bag 2/3 of the way with water. That will help fill in the gaps. Rinse water all over the outside of the bag as well. Then apply directly to the skin for 15-20 minutes, depending on how lean or muscular you are. I go with 15 minutes. Don't go longer than 20. DO NOT APPLY TO SKIN IF YOU ARE USING GEL PACKS!!!! (In fact throw away the gel packs or use them to keep your lunch cold).

Protecting your shoulder means in my case to pretend that there is a wall next to me that prevents my arm from moving outwards (sideways). There is also a ceiling that prevents me from raising my arm forward above shoulder level. Protection also comes from having good posture and keeping the tunnel in my shoulder open, through which the tendons go. If I stand with bad posture, then the tunnel is closed and the tendons rub against bone. If you drop a line down that comes to a tangent with the curves in the front of your neck and your lumbar, it should be perpendicular to the floor, not leaning forward or backward. There should be curves in your spine, but not too big of curves. It's basically the principle of pretending there's a string attached to your head and it's pulling you up. Your lumbar should have a large curve to it, but not so large that you're swaybacked.

For strengthening, I am doing very gentle isometric exercises with surgical tubing. there is a knot at one end of the tube and a loop at the other end of the tube. The knot end goes into the hinge side of the door (this is important because if I use the wrong side of the door, it may come out and snap me in the face). My right wrist goes through the loop and I hold the tubing with my hand. I stand with good posture facing the door, keeping the band parallel to the floor and perpendicular to the door. With good posture, my upper arm at my side, and forearm bent at a 90 degree angle, I step backwards a few steps and hold that position for five seconds. I repeat that 5 times. Then I turn to the left, still keeping good posture, the same arm position, and the tubing perpendicular to the door and parallel to the floor. I step to the left and hold that position for 5 seconds and repeat 5 times. Then I do the same thing facing away from the door and to the right of the door, all while keeping the same posture, arm position, and keeping the tubing perpendicular to the door and parallel to the floor. Then I do everything in mirror image with my left arm, because my left shoulder could use some strengthening as well. I do these exercises every other day.

There's another exercise I do with the tubing, but it's very hard to describe here.

Anyway, the sun coming through my window is beckoning me to go for a good walk. I'm in Missouri and it is almost 60 degrees outside in January. This is not typical, so I'm going now. I'll keep this updated.

Thanks again for all the advice!

Here's an interesting video on the effect of posture on your shoulders. I think that everyone should see this video:

http://www.youtube.com/user/DrGeorgeBest#p/u/25/rSM2JiM25d0

January 29, 2011 at 10:57 PM ·

Fascinating video.  Thanks for posting.

January 30, 2011 at 01:07 AM ·

Mendy wrote: "For work, I got a keyboard tray so that I do not need to raise my shoulders up around my ears while working."

I've always used a tray.  Even though I'm at the keyboard for much of the day, besides about 3 hours each day of practicing and playing violin, I've never had shoulder problems or RSI (Repetitive Stress Injury) from these activities.

I'm amazed that so many workstations these days still don't have these keyboard trays.  When you have to raise the shoulders, it definitely puts undue strain on the muscles.  This pain and strain can then spread to the arms and hands -- causing bow-hold problems like Lisa experienced.

I had a similar problem, but it was from over-training with free weights.  When I sought out some brush-up training from a personal trainer, a former state champion in Michigan, I first showed him my workout schedule.  He looked through it and said, as I recall: "You're definitely over-training.  That's going to weaken your upper body."

He also told me: "It's very important to protect your shoulders.  When you do a chest workout, warm up the shoulders first with a pair of light dumbbells -- 10 lbs. -- because the shoulders are involved a lot in chest work.  Do a set of lateral raises."

I've followed his advice ever since.  The problem disappeared fast.  Indeed, "less is more."

January 30, 2011 at 01:24 AM ·

||:  Alexander Technique :||: Alexander Technique :||: Alexander Technique :||: Alexander Technique|]  D.C. al fine

 

I watched the video.  It described me in October 2009.  (Sorry -- AT changed my life and now I'm a shameless proselytizer :-)  )

January 30, 2011 at 05:55 AM ·

Jenny,

Thank you for the vid!  It provided some medical science behind the AT technique.  I'm guilty of moving my right shoulder in as he speaks of both at work (with mouse use) and while bowing. 

I have found that when I'm on vacation and not doing alot of heavy mouse-work at the computer, the pain goes away, even though I put in many more hours of practicing. 

So with all due respect Peter, I'll stick with my viola and focus on my posture at work. 

January 30, 2011 at 07:03 AM ·

Well, that's good Mendy!!

At least we can't blame the viola for everything. I must say that I had no problems when playing viola, unless we had been doing 21 three hour sessions in a week, or playing the Ring Cylcle over four or five days.

February 2, 2011 at 06:30 PM ·

Today I practiced the very first shifting exercises on the E string from the Whistler books. Yesterday I put my fiddle to my chin and thought, wow! All this equipment I have on my instrument is really heavy and terrible! I'm tall and have a very long neck, so I've been trying to fill up all this space with equipment. I have been dabbling a little bit with my students' instruments in lessons and realized that their setups were quite comfortable and light and easy to play with. I was using a BonMusica rest and I have a tall SAS chinrest, on top of which I put an Impressionist (it's this moldable thing that sticks to your chinrest and is quite heavy. I took off the Impressionist and the shoulder rest and stuck the old cosmetic sponge under a rubber band. Wow did that feel great, except for the fact that my fiddle gouges into my collar bone. So perhaps I'll use a chamois or something. But it felt so good to get close to my instrument and not have all that stuff in the way. I practiced for about 10 minutes today just on the E-string at the upper half of the bow and worked on engaging my shoulder blades, and not just the ball and socket joint. Even then I started to feel a bit irritated, but not in pain. Yesterday was painful. I did some string crossings between the A and E yesterday, so I eliminated the A string for today.

This is going to take a lot of patience, but if Alexander could fix his own problems just by listening to his own body for 7 years, then I can try to do the same.

I went to a masseuse on Monday and that has helped me a lot with getting my neck muscles to relax. They are in really bad shape. Like my physical therapist as well as the one in the video said, if the whole posture isn't good, the shoulder isn't good. If I can't my neck muscles to chill out, I can't get the right posture in my neck. I know that the neck is extremely important in AT as well.

A friend of mine has a very similar body type to mine and she plays beautifully without a shoulder rest. She's about to graduate with her Master's degree. So I think I'm going to use this rebuilding time to learn to play without one. It really felt great for the 10 minutes I played today. My violin professor plays baroque violin, so I'm sure he can help me with that.

February 2, 2011 at 06:42 PM ·

@Smiley Hsu, have you taken your instrument to a luthier to see if your strings are too high? I have a viola shaped object that I used to play a little bit before I got a real viola. Its setup was terrible and I had the same problem. I've never had that problem on an instrument that's well set up.

February 2, 2011 at 10:00 PM ·

Hi Jenny,

Yes, I have.  I had my bridge lowered.  Right now it is close to the lower limit with gut strings.  Since gut is lower tension, the strings have a wider range of motion when vibrating.  Any lower on the bridge and my instrument may start buzzing.  I might be able to cut down the grooves on the nut though; haven't tried that yet. 

February 2, 2011 at 10:06 PM ·

BTW, Glad to see you back to playing.  And you are right, all that extra stuff really weighs a lot.  The Bon Musica is a beast.  I bought one a while back and used it for about 10 minutes before I decided it wasn't for me.  I guess the metal allows you to bend it and adjust the shape, but man does it add to the weight.  Only after playing without a shoulder rest, do you realize how heavy all that extra stuff is. 

February 3, 2011 at 04:26 AM ·

Jenny,

I agree with you on the Impressionist.  I tried it just recently and it added too much weight, even after cutting it down significantly.  Instead I am using a little piece of thin sponge wrapped in chamois and rubber-banded in the one spot where I need a little extra height and padding.

I would love to be able to play my viola with a SR, but I have issues with it teeter tottering from left to right (mostly to the right).  I don't have that problem with the violin without  a SR, just the viola.  I figure it is mostly due to the size of the lower bouts. 

February 3, 2011 at 07:11 AM ·

 Hi, didn't read the whole thread but.... just wanted to say I can really relate to this.  I played for 7 years with an undiagnosed dislocated left shoulder and two subsequent surgeries to correct it, followed by guillain-barre, resulting in much pain during playing (even though it wasn't a violin injury).  Also, like you, the worst pain occurred one day after taking a nap and lying on my left shoulder.  It was just--wham!--unbearable pain until I went under the knife.  I can say this; it DOES get better.  It takes lots of time and patience and the ability to realize that a bad day or setback does not spell the end of a degree or career.

I'm sure this has already been asked, but it couldn't hurt to see other drs just so you can be certain about the dx.  Go to the top, best shoulder dr you can find.  Pay out of pocket if you have to--it's worth its weight in gold (speaking as someone who didn't do this and had to spend 7 years until a correct diagnosis was made).  I have the same body type of you btw... slight, sloping shoulders.  Some body types are more prone than others to injury but that just means you can take certain measures that help prevent injury and stay healthier than all those people who just take things for granted.

One thing I am really careful of when I play; supporting lightly with the left hand.  Not clamping down with my head (there are soloists who do that and I always cringe, wondering how long their body can sustain that).  I know it's your right shoulder though, but couldn't hurt to be protective on the left side either.  You mentioned ridding yourself of the shoulder rest... theoretically it will make things much easier for your right side because the violin is then lower down.  I love the feel of it but my left shoulder needs the rest for now.... otherwise I'd do the same.  I once went overboard, changing many things with my playing at one time but then I couldn't tell what was helpful, so I'd recommend slow changes, only one at a time for at least a week each.  Also, go back into playing SLOWLY.  I really impeded my progress by pushing too much too soon (and it's so tempting to do that, especially after being unable to play for so long).

One of the thoughts that helped me through the times I couldn't play (and didn't know if I ever could again) was to look at the big picture.  It's so easy to jump to conclusions based on what is happening at the moment.  But there is always the rest of your life ahead of you, a long, healthy life which will give you plenty of opportunities to play.  Even if you had to delay getting your degree or taking a semester off.... in the grand scheme of things it is actually a small thing.  Even the worst case scenario, such as multiple surgeries followed by a serious illness, can't stop you (I'm living proof of that ;).  Now that I'm at the other side of the tunnel, I can see how valuable this experience has been.  It taught me to be strong and also, not being able to play just makes your desire for it that much stronger.  Anyway I am also in PT and I know of others who were there for the same dx as you.... they experienced much improvement.  I will send good thoughts, and I fully expect that you will see improvement not only in your health, but your playing as well. :)

February 3, 2011 at 05:12 PM ·

I practiced some more today. More shifting exercises in the upper half of the bow, mostly on the E string. I practiced in front of a mirror today and experimented a little with how I do string crossings. I watched very carefully at how my arm moved at the shoulder joint and realized I needed to engage my shoulder blade more to keep my shoulder tunnel open and just very slowly do only the motions my Physical therapist has allowed me to do. I realized that without the shoulder rest, I could very easily reach the G string without hurting myself, as long as the structure of my shoulder is just right. My left shoulder will need lots of training for this no shoulder rest thing. That's why I think it's good to experiment with it now while I have no impending deadlines and lots of time to rebuild my technique.

My violin appreciates all the weight I've taken off of it. I experimented with putting my shoulder rest back on and it just sounded dead and metallic and dreadful. Took it off and it sounded alive and woody and vibrant. Something I've been missing for a long time. <3

February 3, 2011 at 08:16 PM ·

So glad to hear things are looking up!  Continue to pay careful attention to what your body tells you... it's when we stop listening that we do things to ourselves.

February 5, 2011 at 04:07 AM ·

Well, I don't think I'm going to go without the shoulder rest after all. But I will continue to experiment with and without it. I think what I've learned with my experiment so far is that the shoulder rest is a lot of filler and your body should not brace against it. Whether you use a shoulder rest or not, bringing your left shoulder forward to grip while you're shifting is not going to help you. Without your shoulder rest, your left shoulder will only hit air and won't do anything. With your shoulder rest, it will cause unnecessary crunching. Either way, it should feel as if you are supporting your arm with the bottom of your shoulder blade, which in turn supports the instrument. Experimenting with this has shown me that I was trying to fill up way too much space with equipment and I found a way to adjust my Bon Musica so all it does is fill up just the right amount of space. Before I was trying to get this handy shoulder rest to do all the work. Now I know that I have to do the work and let the shoulder rest just kind of be there to help. I figured out why it was making my instrument sound horrible as well. It was gripping my instrument too tight, so I bent it a bit so it would just gently hold onto my instrument enough that it won't fall off, but not so much that it chokes the sound out. I think people can sometimes get a bit extreme about their equipment either way and I think it's good to find a balance somewhere in the middle.

February 6, 2011 at 07:38 AM ·

 I completely understand what you are going through--I spent half of last year visiting different doctors trying to get a diagnosis that fit the pain I've been going through. It has taken so much time, prayer, and patience...and I still find daily frustrations. However, there are tiny triumphs that we have to celebrate and give thanks for! Today I played for 30-40 minutes...I haven't been able to do that for the past 7 months. In my case, my injury is related to connective tissue (often mistaken for tendonitis, carpal tunnel, or a pinched nerve) and so my physical therapy is a combination of fascia manipulation and Feldenkrais. The Feldenkrais exercises are fascinating and extremely difficult, because they are forcing my brain to move more efficiently than they have in the past. Try this exercise: lightly circle the tip of your finger against the thumb (as little pressure as possible--feel the whorls in the pads) WITHOUT moving your thumb. It is difficult, but it is changing my muscle tone so that I don't tense up out of proportion. 

I also have been experimenting with finding a good shoulder rest/going without, but I would examine your chin rest as well if you haven't already. I ended up getting a custom center-mounted chin rest raised extra high (the shop can do it for you)...I've learned that it is better to fill from the top than from the bottom of the violin. 

Good luck, and have patience! I find that setting little goals for the day helps me feel more accomplished than holding my violin in the practice room wondering if I'll be healthy enough to do a recital next year. 

February 11, 2011 at 12:13 AM ·

@Erika

Wow! That is really difficult. I'm easily amused, so I think this will keep me occupied for a while. I'm glad to hear you're getting back into the swing of things.

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