5 Common Playing-related Injuries in Musicians

Musicians are the unrecognized elite athletes of the art world. However, unlike elite athletes, musicians do not have access to athletic trainers, guided strength and conditioning programs, and paid leave during injury. Furthermore, admitting injury can dramatically alter the trajectory of their careers. The decision to confess often results in feelings of shame and anxiety, which sometimes leads to musicians ignoring or withholding information about pain and injury from instructors or people who may be able to help. Reducing stigma around injury and seeking early intervention is paramount to successful rehabilitation and return to play within the musical community. My goal is to highlight common injuries in musicians, evidence-based treatment interventions, and the role of the physical therapist in injury management. My hope is sharing this information will help reduce stigma around being injured as a musician and help musicians seek care early on when experiencing pain related to playing.

There is up to a 93% lifetime prevalence of injury in musicians, meaning that 93% of musicians experience some sort of playing-related injury during their careers.1,2 There is a significant lack of high quality research regarding the topic of which instruments have highest injury rates and the types of specific injuries2, but there is enough evidence to make some general statements, which should not come as a surprise. Instrumentalists who hold their instruments in asymmetrical postures tend to report higher rates of injury (violinists, violists, flautists, etc.).3 Most literature regarding the study of musicians is pulled from orchestral and classical musicians, leaving a huge gap in the literature for injuries experienced by musicians outside of the classical world, such as pop/rock, jazz, and folk, of whom I suspect there is an equally high if not higher incidence of injury due to a tendency of many of these musicians to go without formal training.4 Realization that such a high percentage of musicians experience injury during their lifetimes should help reduce feelings of shame and incentivize musicians to step forward and admit injury in order to get adequate early intervention instead of waiting until the injury has become chronic.

What injuries do musicians experience?

Overuse injuries are probably the most commonly experienced injury incurred by musicians. This generally relates to injury of tendons, muscles, and joints. The pain can be described as dull and achy and is directly correlated to an activity. Pain often does not come on immediately during playing, but begins to be painful an hour or so into practice. Sometimes pain is not felt until after practice is stopped, which often leads many musicians to play through the pain, making matters worse. Overuse injuries occur most commonly when practice time or intensity is suddenly increased or when the duration of practice is too long with insufficient rest during the session, which causes tissue breakdown to occur at a faster rate than tissue repair.3,5 Musicians commonly experience this type of pain in the forearm, shoulder, or neck. 

Neuropathies are another common injury amongst musicians. Simply put, this means any injury to a nerve. In musicians, it typically occurs in the form of nerve compression, which can occur anywhere along the course of a nerve. In upper string players, this can be a result of having the head turned to the left and side bent while holding the instrument, which can compress the cervical nerves of the neck which supply the muscle, joints, bones, and skin of the arm. The nerve can be compressed where it exits the spinal column or it can be compressed in the thoracic outlet, the area between the shoulder and spine itself. The reason nerves can get compressed here may be due to adaptive shortening of the scalene and pectoralis muscles, elevation of the first rib, or depression of the clavicle as a result of how upper string players must hold their instruments and the direct contact of the instrument to this region. Other common areas for nerve compression in the arm include the elbow and wrist. Nerve compression injuries can be experienced as fuzzy, tingling in the arm or hand, most commonly the hand or fingertips, weakness in arm or hand, or sometimes shock-like, electric, shooting pain down the length of the arm occurring intermittently when the nerve is stretched or compressed. Though most common in the upper extremity for musicians, neuropathies may occur in the low back and legs due to prolonged sitting or standing with poor posture, often referred to as “sciatica.” Removal of nerve compression or tension should help to alleviate symptoms.

Both wind and upper string players report high rates of temporomandibular joint (TMJ) pain and dysfunction, around 61%.6 This can be experienced as pain in or around the muscles or joints of the jaw or upper neck. It can also be experienced as clicking/popping and sometimes locking of the jaw with opening or closing of the mouth with or without pain. It can occur as a result of stored tension in the jaw due to stress, poor head/neck posture, increased muscle tension during playing, prolonged biting of the reed in woodwind instrumentalists, prolonged compression of the jaw upwards by the chinrest of violinists and violists leading to a lateral shift of the jaw toward the right.6 Anecdotally, brass players often experience orofacial pain and facial muscle weakness, leading to potential inability to purse lips tightly and the possibility of drooling out of the sides of the mouth due to overstretched muscles of the cheeks and lips. 

Postural pain is widely experienced by all musicians due to prolonged sitting or standing in one posture for hours on end, which is amplified in players who hold their instruments asymmetrically or have arms elevated during playing. It is most commonly experienced in the neck, upper back, lower back, and shoulder girdle as a dull, achy pain which is relieved by stopping playing or changing position. Musicians fall in the extremes of posture. Often, I see musicians who are hyper aware of their posture and sit with beyond perfect posture, leading to arching of the lower back, forward tilting of the pelvis, and flattening of the thoracic spine, which causes over-activation of the long spinal extensors, primarily fast-twitch muscles not equipped for the endurance required of postural muscles, leading to fast fatigue and pain during playing. On the other end of the spectrum, I see plenty of musicians with the more typical forward head, slouching posture as a result of tightness of the chest and upper trapezius muscles with corresponding weakness of the deep cervical flexors, serratus anterior, middle and lower trapezius, commonly referred to as a upper crossed syndrome. With both extremes, there is often corresponding poor core stabilization strategies, which may be a risk factor for developing postural pain.

Hypermobility can refer to excessive motion or laxity in a joint. This can be global (all joints) or localized to a single or a few joints. In global hypermobility, musicians experience deficits in proprioception and kinesthetic awareness and weakness associated with a general reduced ability to control motion and maintain safe mid ranges of motion. Proprioception and kinesthesia refer to our ability to sense where our body is in space. An example of global hypermobility is the musician with postural pain (above) who sits with excessive arching of the lower back and forward tilting of the pelvis. This player is using the joints of the spine and pelvis to create a false or passive stability in order to maintain posture. This player may feel a constant need to shift or change position frequently (lack of control of available motion due to weakness and proprioceptive deficits). Pain is often felt in extremes of ranges of motion and the quality and location of the pain may be inconsistent. 

Localized hypermobilities, on the other hand, are typically adaptations to playing, for better or worse. This occurs when one or a few joints work to accommodate the range of motion necessary to play specific instruments. Examples are often seen in the phalangeal joints of the fingers, most commonly the thumb and/or pinky. Think of the guitarist whose interphalangeal joint of the thumb collapses or hyperextends on the neck of the guitar of the fretting hand or the middle interphalangeal joint of the pinky finger of a violinist which collapses or hyperextends on either the bowing hand or the fingering hand. These are the result of overstretching of the ligaments of these joints due to repetitive use of faulty hand postures and usually are accompanied by surrounding muscle weakness or over-activation in some cases. Hypermobilities are what are commonly termed being “double jointed.” In reality, there is no such thing as being double jointed, more likely the joint has excessive motion and is more appropriately deemed hypermobile. 

Infrequently, 1% of all musicians develop musicians’ dystonias.7 In this injury, we observe involuntary contraction of a muscle or muscles, typically in the fingers. This is seen as uncontrollable curling of the fingers during playing. It is most commonly seen in guitarists, pianists, flautists, and string players. Emerging research tells us this may be the result of inaccurate somatosensory input both locally and further up the kinetic chain accompanied by inaccurate processing and integration of the somatosensory input at the level of the primary sensory and motor cortexes in the brain.7 I highlight this condition here because it is one of the most well researched areas of performing-related musculoskeletal disorders, but it is also the most uncommonly experienced of the injuries written about in this article. Optimistically, the emerging research regarding this condition is providing physical therapists and other professionals in physical medicine ideas for treatment strategies to help modulate and retrain sensory input to reduce symptoms. 

What treatment interventions are used to help musicians overcome injury?

First and foremost, proper education regarding safe and realistic practice routines and proper playing posture will help to prevent injuries from occurring. Education regarding the importance of rest and relative rest during and after playing is also useful for prevention and for rehabilitation after overuse and postural pain injuries.3 Musicians should incorporate aerobic exercise into their weekly routine to improve general stress and wellbeing as well as provide adequate blood flow needed for tissue repair and regeneration.3 Additionally, musicians should incorporate cross training into their routine, which may include a strength, conditioning, and flexibility program in order to improve stamina and reduce pain during playing.3 Specific warm ups and cool downs individually tailored to an instrument should be developed. Understanding the role of nutrition and hydration can help to reduce injury risk and may facilitate healing once injury as occurred.3 Targeted exercises developed by a healthcare professional, such as a physical therapist, will be necessary in recovery depending on the individual, instrument, and injury. Adaptations or adjustments to the instrument or its associated assistive devices themselves, such as chin rest or shoulder rest of violinists, may also help reduce the effects of or prevent injury. Alteration of the ergonomics of a practice or performance space can greatly improve body mechanics during playing, thus reducing injury risk or symptoms. Finally, musicians must have techniques to manage stress and reduce tension during playing to help improve quality and efficiency during playing while also reducing risk of injury or pain.3

The Role of the Physical Therapist in Managing Performance-related Musculoskeletal Disorders

I want to make a strong argument for the PT as being the first healthcare provider musicians should consult with for playing-related injuries. PTs are biomechanical experts whose job is based on developing strategies and interventions to improve function. In musicians, this function is your ability to play your instrument well, with proper posture, with good ergonomics, with efficiency, without pain, and without unnecessary muscle tension. This is the cornerstone of good, professional-level playing: relaxed, seemingly effortless technique. Upon consult with a PT, they will perform a full biomechanical exam and screening to determine the tissue at fault, come up with a working diagnosis and develop a plan of care individualized to your needs. This may consist of manual therapy techniques, practice routine modifications and development of safe return to play schedule, flexibility and strength programming at the functional level and for cross training, postural re-education and training, ergonomics analysis, instrument modifications, bracing, splinting or taping, stress management and proper breathing techniques, and instrument-specific exercises to improve technical efficiency and finger independence.3

Take it one step further and find a PT who is also a musician. This PT will better understand the specific demands required of being a musician and will have a more targeted approach with playing-related exercises specific to your instrument. We are few and far between but we are out here and our community is growing.

REFERENCES

1. Zaza C. Playing-related musculoskeletal disorders in musicians: a systematic review of incidence and prevalence. CMAJ. 1998;158(8):1019-1025.

2. Rotter G, Noeres K, Fernholz I, Willich SN, Schmidt A, Berghöfer A. Musculoskeletal disorders and complaints in professional musicians: a systematic review of prevalence, risk factors, and clinical treatment effects. Int Arch Occup Environ Health. 2020;93(2):149-187. doi:10.1007/s00420-019-01467-8

3. Chan C, Ackermann B. Evidence-informed physical therapy management of performance-related musculoskeletal disorders in musicians. Front Psychol. 2014;5. doi:10.3389/fpsyg.2014.00706

4. Kok LM, Huisstede BMA, Voorn VMA, Schoones JW, Nelissen RGHH. The occurrence of musculoskeletal complaints among professional musicians: a systematic review. Int Arch Occup Environ Health. 2016;89:373-396. doi:10.1007/s00420-015-1090-6

5. Kumar S. Theories of musculoskeletal injury causation. Ergonomics. 2001;44(1):17-47. doi:10.1080/00140130120716

6. Jang J-Y, Kwon J-S, Lee DH, Bae J-H, Kim ST. Clinical Signs and Subjective Symptoms of Temporomandibular Disorders in Instrumentalists. Yonsei Med J. 2016;57(6):1500-1507. doi:10.3349/ymj.2016.57.6.1500

7. Konczak J, Abbruzzese G. Focal dystonia in musicians: linking motor symptoms to somatosensory dysfunction. Front Hum Neurosci. 2013;7. doi:10.3389/fnhum.2013.00297