Physical changes in the shoulder for a violinist

May 17, 2016 at 01:31 PM · Fellow violinists, when in front of a mirror (without a shirt for visibility) you raise your arms to the sides, will your right shoulder automatically raise higher than the left one? This happens to me. This is supposedly a normal change in violinists' anatomy, but what are your experiences?

Related or unrelated to this effect, I do have some trauma on my right upper arm. I'm going to have an MRI soon for that. What has happened to me is that 5 years ago my upper arm started to feel pain "inside" in a weird way. Basically the pain was the same as what happens if you throw a heavy ball too powerfully and you hurt your upper arm. Over the years the pain has gotten worse and now I can't sleep normally. I have to sleep only on my back and I have to turn my right upper arm left on top of my leg or chest. If I keep the upper arm normally next to my leg, that will create a lot of pain during the night.

My right arm's range of motion is decreasing. Can't lift it very high, can't turn it backwards very much. It feels as if the upper arm tendons/muscles have shortened and hardened so that the wide movement is both painful and possibly also impossible. Nothing abnormal was shown in x-ray and ultra, so the MRI is now important.

During the last 5 years I have not played the violin much anymore and in my opinion I do not strain the arm in any way. My left arm is totally normal and painless. Any keyboard typing work etc. should be quite evenly distributed between my arms. So it feels like the upper arm is somehow deteriorating by itself with no physical cause. Though it's possible that I damaged it already 20 years ago by throwing balls too powerfully and it just didn't show symptoms back then.

Has anybody experienced a similar problem?

Replies (25)

May 17, 2016 at 02:18 PM · 1. Years ago I suffered significant right shoulder limitations after changing the computer mouse I used - a bad choice just to save a very few dollars. That did not affect my bowing - but it permanently wrecked my ability to throw a ball.

2. Constantly sleeping on the right side without enough cushioning can affect your bow arm.

3. Sitting for long times in an arm chair (airplane seat or car seat) that pushes up on your arms, even a little bit, can affect your shoulder muscles.

4. Check the internet for shoulder PT exercises. One I think can work wonders is simply holding your shoulders as far back as possible, as if "hunching" your shoulders - but backwards instead of forwards. You can do this a few seconds at a time throughout the day - if you want.

Andy

May 17, 2016 at 02:33 PM · I had never heard of the shoulder thing before so I just tried raising my arms while looking in the mirror...my shoulders appear completely equal in height. I have been playing the violin for nearly fifty years.

I am sorry you are suffering so much pain.

May 17, 2016 at 05:23 PM · No, neither shoulder should be higher than the other!

Find a good physiotherapist to work on tightening certain muscles of the shoulder and bring it back to balance.

From what you described it looks a bit like a "frozen shoulder".

If you hear some strange Latin words such as...

Infraspinatus Teres Minor, Subscapularis, Lattismus Dorsi, Supraspinatus

... chances are your physiotherapist knows his/her job.

The pain you have been experiencing may be due to shoulder being elevated. It puts all muscles of your arm into stressful position and this may lead to all kinds of troubles (nerve compression or impingement, tendon tear, etc)

Once your shoulder is back to where it is supposed to be, revisit your posture and accessories (shoulder rest, chin rest). Raising bowing arm sometimes results from a too high shoulder rest (vertical plane) and/or poor position (horizontal plane) and the tilt of the violin.

R

May 18, 2016 at 09:24 AM · Thank you for the interesting answers! I am actually going to have a very expensive 3T MRI scan today so I'll get new informarion from that. But here are some things about my particular case that I'm fairly certain about:

1. I have chosen my computer chair (arm rest height and width), keyboard, mouse, sitting postures, table height etc. quite carefully. I feel that they are in perfect balance. My mouse is a light one, I dislike heavy mouses. (In particular, I love Logitech MX518 or G400 and for the keyboard, Logitech K800 for it's feel and quietness.)

2. I don't think I can sleep better way I'm already sleeping. Which is on my back, keeping right hand mostly on top of my thigh or kind of on my stomach but with some blanket so that the arm is not tilted too much.

3. Arm rests pushing the arms upwards is an important thing to look at. I think for me too much push up is not good. But arms hanging loose downwards, that's even worse for me, I think. The arms are getting pulled out of the sockets that way. A middle position seems to be the best.

4. I have to do more exercises, that's for sure. I have to consider the fact that my left arm has no problem whatsoever even I am sitting on the chair in the middle with same arm rests, so the posture is quite even. But only my right arm has problems.

5. The right shoulder being higher: I want to emphasize that I don't believe my right shoulder is high while playing and it is not high while I stand in front of a mirror arms down. It happens when I lift the arms, then the right shoulder raises higher than the left one "by itself". I think some violinists do have this, even perhaps without any problems, are there any of you reading this?

6. In my case, the problem is probably actually not due to anything related to what I'm doing with violin nowadays. Because I have not played the violin much for the last 7 years or so, but the problems started 5 years ago. However, what I did with violin 20 to 7 years ago, thay may or may not have a role. Might be due to some sports too although I never had a major injury.

About violin technique and for the little finger's role, I do have a bow technique which uses the little finger, I have built my bow technique partly with finger collé which helps you explore the little finger's possibilities. And at frog, letting the sound come from just holding the bow in place with little finger, no force on other fingers, that is an amazing way to learn healthy sound production. At frog, the left part of the bow has lots of momentum and weight, producing the sound by itself.

May 18, 2016 at 12:54 PM · I also have a higher right shoulder from playing, and have no problems.

May 18, 2016 at 12:59 PM · I've got the MRI results. I'm going to go through the results later with my physiatrist. But I got a CD with the 2D images. I've got 6 sets of 2D slices, 17–25 images per set. The images seem sharp enough. Anyway, the result was that one of the tendons have a 12 mm long, 8 mm wide tear. One third of the thickness of the tendon has torn.

I do not remember any other accidents other than only throwing balls. Particularly in school when there were throwing competitions, over 20 years ago. My arms are fairly long which most probably makes me more prone to this kind of accident. Also if I jump rotating 360 degrees (kind of like in ballet), I usually have both my arms hurting. Probably just because of my anatomy.

It is possible that something else happened to the arm that I just don't remember (might've been 20 years ago). But seeing the result, I would say be a bit careful when throwing objects very hard if you have long arms.

May 18, 2016 at 01:50 PM · Just to set things straight - it was not the weight (mss) of my computer mouse that caused my shoulder problem, it was simply its shape.

Andy

May 18, 2016 at 02:26 PM · A.O.

If you observe some of top violinists today, they do lift their right shoulder... it is just a matter of time before they will get injured. Elevated shoulder is not a natural position and is calling for a trouble. It is a very complex joint and has to be in optimal position and well balanced in order to perform well.

Jukka,

Please read this book before making any radical decisions about the treatment:

http://www.stouffvillemusiciansinjuriesclinic.ca/book.html

Also, talk to your physiotherapist about the usage of kinesiology tape. Depending on the type of injury, particular placement can help you to avoid getting injured more. [For example, if you apply the tape across the deltoid muscle (you can imagine a V - shape, coming from the corners toward the back bone), it will remind you whenever you elevate or pull your shoulder forward.]

Again, the challenge with shoulder injuries is that, once the pain is there, we sometimes (unconsciously) avoid certain movements, which leads to "frozen shoulder" - posing new challenges altogether! You need a good orthopedic physiotherapist very soon.

Rocky

May 18, 2016 at 02:40 PM · Jukka, IMO, it seems you have rotator cuff injury. Some of the shoulder muscles are tightening / lifting to minimize the pain of the injured tendon. Tendons take 6 to 12 months to heal, when they are carefully and seldom used. They have no blood supply, so healing is very slow. You need assessments from professionals about whether this injury will heal, or whether you need surgery.

May 19, 2016 at 12:01 AM · Rocky: My right shoulder is higher than left, but it is not because I raise it (I hold the left arm on the low side bec. Short arms), but simply the body adapting to the violin.

Ex: My collarbone has enlarged outwards to better prop up my sr less violin, just with natural playing position. :)

May 23, 2016 at 08:49 PM · Thanks for the reference, Rocky! I got the book for my Kindle, but I shall order a paper version to be able thumb back and forth, or keep my finger on the illustrations. It's readable, with good sense, good humour, and just the right amount of science.

May 23, 2016 at 11:58 PM · I am mostly a maker but I had a frozen shoulder (left) that prevented me from playing for months... some years later I had it again in my right shoulder... For the left shoulder I needed 43 sessions of the physiotherapist , 60 for the right one...

May 24, 2016 at 10:51 AM · well, doing yoga properly could've helped :)

June 2, 2016 at 12:25 PM · I would recommend for anyone having shoulder pain, see a doctor to rule out a tear, then see a physical therapist. My physical therapist had great advice on how to place pillows to support my shoulder - I was having same severe pain which would increase as the night went on and over time, then not go away even if I got up. Also, the therapist can show you exercises to increase blood flow to shoulder, and do physical manipulations "unfreeze" it. You also get exercises to do at home two or three times a day.

This would obviously take place after your surgery, but for anyone else reading and has pain like this - see a doctor! Therapy takes several months, but now I am mostly pain free.

As you get older, the tendons tear and strain much easier.

Forgot to add - had same limitations of movement, but lucky for me, MRI showed no tear.

June 23, 2016 at 12:37 PM · My situation has cleared up a lot since I wrote the last time. I took the 3T MRI scan and it revealed certain things clearly. A third of the thickness of my supraspinatus tendon has been torn. That has happened because the bone above supraspinatus is grinding a bit on the tendon. That happens because the rotator cuff is inflamed and swollen and because the bone is or has become (too) thick. So both sides are making the room for supraspinatus too small. So that's the difficult problem to heal (or if not difficult, at least expensive). Options are to grind a bit off the bone and depending on how much/soon I'll tear the supraspinatus more, that has to be eventually reconnected as well if I break it completely.

The orthopaedist I went to see claims to be one of the leading experts of shoulders in the world. In any case, my problems seem somewhat clear now. The information I got previously from a normal doctor, physiotherapist and physiatrist were quite misleading and clueless even. They had no idea how to read the MRI scan images (which were 6 different sets of 2D image slices). The orthopaedist could see the problems immediately.

Even though I have the supraspinatus tear, if I don't plan to do any rough sports involving strong and quick movement of the upper arm, there may not be acute problem with the supraspinatus. Other than I have to be careful and avoid hard throwing etc. The tendon may snap completely, but it's difficult to say whether it's good to do a surgery for that at this point.

But the acute problem was, as suggested, frozen shoulder. So my rotator cuff was thickened (inflamed), at some places several millimeters. That causes both mechanical blocking for stretched positions and pain. So as suggested by the orthopaedist, I took a cortisone injection inside the shoulder. So that made the shoulder really sore for the evening, but beginning from the next day, the pain was reduced to a fraction and the mobility was restored to very good already. Not perfect yet, but now it feels much more normal to stretch and use the upper arm. So at the moment it seems like it's healing well, even having had the time to do only moderate amounts of stretching right now.

So it was really surprising to learn how unintuitive the frozen shoulder is. I need to stretch it a lot which is opposite to what I thought and opposite to what my physiotherapist said. She said the problem is caused by hypermobile joints, which, according to the orthopaedist has nothing to do with my problems (neither frozen sholder nor the supraspinatus tear).

Based on my experience so far, I would say that if you have pain in the upper arm (especially) during night, do not start using and stretching the arm less but the opposite. Stretch a lot to all directions even it hurts a bit. Perhaps quick hard movements are not good, though I don't know if the pain in a frozen shoulder is really a signal for something bad happening or a kind of false alarm. Also I don't know whether the cortisone really healed the rotator cuff or just reduced pain, but it certainly feels a lot better now. It's like a hardened old arm just got a lot younger again.

June 23, 2016 at 01:49 PM · Jukka,

"The information I got previously from a normal doctor, physiotherapist and physiatrist were quite misleading and clueless even."

That sums up my experience with 50% of local experts.... and I am very sorry to hear about the diagnosis.

Now that you know the facts, the orthopedist should write a note to your physiotherapist about what needs to be done. From what I have red so far, cortisone injections are not solution; yes, they can provide immediate relief, but in the long run you need to work a lot on physical therapy. Also, I hope that your orthopedist is not "scalpel happy" and that surgery will be considered only as a last resort. Bones are the way they are.... but the main challenge is about the loss of balance and probably loss of muscle mass.

From my personal experience, the main challenge is loss of trust in experts when it comes to physical injury. When we do not see results after spending money and time, we turn to other sources of healing and try to self-heal... which is also like throwing the dice. You need to stop playing and abstain from other aggravating activities as much as you can.

Try to accept the fact that, even if you get all proper resources (knowledgeable experts) and work diligently, the healing will take a long, long time. In other words, no violin for 6 to 12 months, if you want to ever play again.

Contact Barbara Paull @

http://www.stouffvillemusiciansinjuriesclinic.ca/

She might be able to recommend a great physiotherapist in your country and also shed some light on the process.

Good luck!

Rocky

June 23, 2016 at 02:08 PM · My situation was very similar to yours - the cortisone injection helped the swelling go down so I could do physical therapy. I really recommend seeing a physical therapist, as he/she can show you the right exercises to do, and also manipulate your shoulder for you to gain more mobility. Doing the exercises three times a day for 15 min really made a difference.

I would not say you have to stop playing in moderation, as you remarked, working out the shoulder is actually good as it builds muscles and increases blood flow - but I would see a good teacher to verify you are holding the violin in a way to not injure yourself.

I worried I would not be able to play again, but I can, however I do take frequent breaks - play 15-20 min, stop, rest, play again. I think the exercise will retain mobility in my shoulder - NOT working it can lead back to "frozen shoulder".

June 27, 2016 at 03:28 PM · About the bone grinding: my orthopaedist seemed very confident about his craft and the grinding of the bone above supraspinatus seems to be an easy procedure for him. However, I certainly don't prefer any surgery and at the moment I do not consider it at all. I would however like to be able to throw ball strongly without the danger of completely snapping my supraspinatus, but I'll have to tackle that problem later.

The range of motion at the moment is quite good for me, so much better than before cortisone. Though I think the effect of the cortisone has already slightly dropped now. Perhaps it means the cuff is getting more inflamed again. But as my arm now moves or moved better than before the cortisone, perhaps that indicates my cuff is not completely hardened/thickened/shrunk because of scar tissue but the movement is also reduced by just inflammatory pain (versus mechanical lock). This article http://www.sosmed.org/specialties/shoulder-elbow/frozen-shoulder-syndrome-adhesive-capsulitis/ mentions that there are (at least) two types of frozen shoulder: with scar tissue and without.

All articles talk about inflammatory, freezing, frozen and thawing phases. For me though, I am not able to say which phase I'm in. For me it started noticeably about 6 years ago, gradually worsening say 10 % per year or so. Maybe I'm in the frozen phase as non-steroid anti-inflammatory medications do nothing for me. However, cortisone helped very much which (according to the text) indicates inflammatory or freezing phases (as supposedly it reduces inflammation).

The text says the range of motion may not start getting better before six weeks of stretching (and gentle muscle strenghtening) has been carried on. So I have several weeks to go still. I did do some occasional stretching and muscle exercises already 6 months ago, but the instructed stretching was extremely mild back then, so I think that wasn't adequate at all. This is exactly for me (from the article): "Our repeated observation is that may patients who have failed previous physical therapy will benefit from further treatment once the appropriate diagnosis has been established and the exercises focused on stretching rather than strengthening."

This seems to be a very tricky problem with quite varying opinions on what to do and not to do as treatment. There are many opposing instructions at different sources. YouTube seems to have a bunch of very interesting videos about the subject (for example https://www.youtube.com/watch?v=bKRWqOPmsL0 ), containing quite different approaches. At the moment I will continue playing the violin because the range of motion necessary is not at all painful. Also I had the problem already for over 5 years, during which time my occasional playing did not make it any worse, possibly on the contrary.

There are many mysteries still left unresolved, I will try to figure them out as my problem persists. For example why does the situation get worse during night at the most relaxed arm positions? Is it actually related to the neck and head?

June 27, 2016 at 05:06 PM · I can answer that - at night your shoulder is not relaxed, you are sleeping on it, causing the muscles to tense. As they tense, the pain builds, causes more tensing as you react to it......more pain.....This can be partially alleviated by supporting the affected should with pillows, sleep on your back. Several pillows! I put one under arm, one under shoulder, and another on the other side so I wouldn't turn over. Try to keep your arm and shoulder all in one plane - think of the violin method - no crooked lines.

I had the same question, and this is what my physical therapist told me, I followed his pillow advice and it cut the pain in half.

June 27, 2016 at 06:38 PM · All this pillow talk is making me blush.

June 29, 2016 at 01:30 PM · The pillow trick: This seems to be one of the things that get opposing instructions depending on source. For many weeks I tried to figure out what are good and bad positions for my arm during night by experimenting. It was very difficult to get valid results for many reasons (impossible to know exactly what happens during sleep and when I thought I got a result, it seemed different the next day). So far I have given up with pillows. I can basically say that the shoulder and upper arm gets (or got) sore during night regardless of efforts keeping the arm and shoulder at any given position the whole night, with or without pillows – however I didn't try the upward position yet. I haven't slept on the sore side much at all. But I have slept a lot on the back, as relaxed and straight as possible. At least that strategy does not work, that causes soreness.

Different syndromes seem to be easily confused between eachother, which makes the subject more unclear. The description in this video https://www.youtube.com/watch?v=81XmhQxWVSo mentions that "shoulder impingement syndrome" is easier to fix than a frozen shoulder. SIS is also controversial according to https://en.wikipedia.org/wiki/Impingement_syndrome

Here they suggest this kind of optimal sleeping position: http://frozenshoulderclinic.com/frozen-shoulder-exercises/

June 29, 2016 at 02:56 PM · Sleeping up might help - I bought an electric recliner to use after a different type of surgery, but I think that would have helped. I recommend an electric rather than manual, as you can really adjust the positions in minute increments vs, large shifts.

Sleeping on the sore side is definitely a no for me - now two years later sleeping on that side will cause the pain to return.

I will add as a caution to others - seek help when it first starts to hurt - do not try to "tough it out" as popular culture tells you. Follow the violin playing advice - if it hurts, it shouldn't. Had I seen a physical therapist a few months or even weeks after the pain began, it would have been far easier to help, and not as permanently damaged. I waited to long, till I could not sleep for more that an hour or two at a time.

June 29, 2016 at 07:09 PM · I agree with "seek help when it first starts to hurt" and would add:

be assertive in getting help; ask explanation, report progress or the lack of it - do not hesitate to look for a better therapist if there is no progress.

There are many "experts" not worth their title.

Educate yourself.

Pay attention to your diet.

Do some light cardio exercises before you start playing.

June 30, 2016 at 02:04 PM · Whenever I have had mysterious aches in fingers, hands or arms I resort to simple yoga exercises. This seems to have worked up to now but maybe not forever.

On line yoga is now very much "sitting down" but the important action is above the waist for the violin anyway.

You Tube is loaded with sites.

It may take a few days to notice advantages and yoga may not work when professional medicine is the more proper answer.

August 16, 2016 at 01:12 PM · An update for my frozen shoulder issue: There are some many theories and remedies for frozen shoulder on the Internet. However, this is what I have now done. I had "pain inside upper arm" for many years. About 1–5/2016 was the worst peak for me. Average frozen shoulder severity at most. I could turn my straight arm up on the side until about 10 cm from the head. That was the point where pain prevented turning the arm more. At that point the shoulder would considerably lift up (a part of the illness).

Then, one shot of cortisone was injected in the shoulder. On that day there was tremendous pain but still I did a lot of stretching to all directions hourly. Then I continued stretching multiple times per day for about a week. Then I didn't have much time to do the stretching any more (I was occupied in a music course playing the violin etc.).

For the 6–8/2016 I haven't done so much exercising at all, I will start doing more though. It could be even said that I haven't done anything except simply placing my arm in maximum positions before going to sleep. More specifically I have put my arm to e.g. this kind of position: http://frozenshoulderclinic.com/frozen-shoulder-exercises/ and the last picture. Though my bed's edge doesn't allow that exactly, so I have also simply laid on my back, putting the arm up, bending to the left. And so on. To any position that feels extreme and hurts a bit. The hurting stops in just seconds. Keeping the position for a few minutes feels ok, but probably doing too extreme positions for hours would not be good.

So. I can't know exactly what helps and what doesn't, but I think the cortisone helped tremendously and I didn't even have to do so much stretching, just moderately. My doctor said I could have another cortisone shot also if I wanted. So far I don't feel I need it because the arm is already so much better. I do want to get rid of all remaining pain though, so I will continue stretching, general physical training and we'll see the status again later on.

One interesting thing is, that sometimes when I do those maximum positions before sleeping, I feel as if little strings are snapping inside the shoulder (not really painful). Kind of like the picture's http://www.moveforwardpt.com/image.axd?id=ed7e51c8-0b0e-433b-aa09-22bc0ef8c819&t=634575692976730000 red adhesions would be snapping. This could be a false observation, but something like that might be happening. A weird illness this is.

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