Too Much, Too Soon?

We’ve all witnessed the spectacle of the twelve-year-old playing Tchaikovsky’s violin concerto. Where they were once the exception, the outstanding child artist is now a fixture on the concert scene. But at what cost? Among teachers, doctors and therapists, there is a concern that developing muscles and bones may be damaged by repetitive activities. Younger and younger instrumentalists play in pain. Even amongst young players, the length of symptoms is alarming, and can become chronic or career threatening.

How Do Injuries Occur?

Overuse is a loose term applied to several conditions in which body tissues have been stressed beyond their biological limits. Repetitive action, especially when combined with poor posture, excessive force and tension, and insufficient rest or breaks can bring about an overuse injury. Other factors also contribute to risk: our body size and build, our conditioning, muscle imbalances, fatigue and stress, as well as the obvious, our “technique” or physical attitude to our instruments. But young people have additional concerns.
Adolescents experience growth spurts that put them at particular risk for injury. “When young people grow, their bones grow first and then their muscles catch up,” write Barbara Paull and Christine Harrison in their book The Athletic Musician. Studies are finding that some types of stress on the growth plates (the area next to the joint where bone growth in length occurs) may cause problems during development. When bones grow faster than muscle, it is important to strengthen and stretch the muscles in order to protect them from strains and micro-tears that may result from intense use.
“An untoned body is more injury-prone by being less resilient and by failing to provide the needed support for the muscles more immediately involved in performing … Playing instruments is a physical, highly demanding and coordinated activity. Overall physical conditioning is of the utmost importance to prevent injury,” writes Alice Brandfonbrener, M.D.
Too many young students sustain injuries that may lead to chronic difficulties that thwart their musical lives. Education in prevention strategies is essential. Here are four important rules:

1. Warm up
2. Take breaks during practice
3. Increase your practice load gradually
4. Vary your repertoire while practicing

Be wary of sudden increases in practice or playing time, a change in instrument or teacher, or preparation before a jury, recital or audition. Students are especially vulnerable at these times. Also, watch out for extremely intense summer music camps with repertoire requirements that seem unrealistic.
Tolerance levels vary with every individual. Some students are more susceptible to injury. It is important to set realistic goals for levels of performance, by appropriately assigning repertoire, and monitoring the number of performances, contests and competitions. Programming should be considered as well, avoiding recitals or programs that contain several works that are new to the student at one time. Too much, too soon is a set-up for injury.
Concerted efforts to reduce stress are paramount. There are many excellent programs to take advantage of, including yoga, Alexander Technique, Pilates programs and the like, but swimming, a baseball game, or a bike ride can work well too! Avoid weights, and use common sense when engaging in sports. Overall conditioning is important, and so is warm up before rigorous activities and before practicing and performing!
Always seek a teacher who pays attention to all the physical attributes of the student. The most important thing is that attention be paid to good posture, ease of technique, and proper technical set-up at the onset of study, before problems ensue and are difficult to correct. Practice habits, type of repertoire, instrument size and weight, stress levels, schedule, and outside activities should all be taken into account. Be wary if a young person is struggling physically with an instrument. It portends trouble down the road. Use common sense when monitoring the musicians’ activity level and improvement.

How To Avoid Injury

Choosing the right size and weight of your instrument is critical for the musical and physical development of all players. Choose instruments carefully. Look for ease and responsiveness. Strings should be low, necks should be slender, bows should be light. Instruments must be in proper repair so that they function appropriately and easily. When in doubt, go with the lightest, smallest instrument.
There are many instrument modifications available to ensure your comfort while playing. There are many straps, splints, and devices available to help hold instruments. The Kun Company now makes shoulder rests with extra long screws to raise the shoulder rest. There are new chin rests available as well. Experiment so that you fill in the space between your chin and your shoulder to ensure comfort, that your left shoulder can stay down and in neutral, and that your head is upright. Be aware that the one-size-fits-all approach does not work on any instrument.
Chair height is also critical. There are many adjustable chairs and stools available so that you can sit with good posture. Always try to stay in neutral or a natural posture with your head upright, your shoulders down, and with a natural curve in your lower back. Sit upright with your weight forward and your feet firmly on the floor. Make sure your torso is not turned or twisted, your head is not cocked, and your chin is not jutting out.
Musculoskeletal injuries are frequent in musicians with joint laxity (double-jointedness or hypermobility). Although many music teachers find these youngsters very flexible and therefore good candidates for instrumental playing, they may in the long run experience problems with pain that can become chronic. Studies show that injury risk is higher in musicians with laxity. This may be due to the fact that the instrumentalist must use more pressure to stabilize and “brace the joint” to prevent it from collapsing.
These musicians should be assessed. If you have hypermobile joints, it is of the utmost importance to use prevention, avoiding more long-term and extensive hyperlaxity. It is important to learn careful technique, eliminating grabbing and pressing with fingers, and to learn joint protection.
There are many ring splints available that can help prevent the buckling of finger joints—some are even stylish—and can be used for practice as well as performance. Consult a qualified physical therapist. Theses devices are by prescription and must be fitted. Therapists will also be in a position to guide you on strengthening hyper lax joints safely.
It is essential not to slam fingers down on any instrument. “Banana fingers,” or fingers that are softly curved with some length, is a good analogy. Focusing on up action (which emphasizes release) is preferable to down action (which may result in squeezing). Listen for “snapping” or “slapping” strings or keys, which may indicate too much finger pressure.
String players: watch for excessive calluses, grooves, or torn skin in left-hand fingers, as well as collapsed knuckle joints and squeezing thumbs. You are either pressing too hard or your bridge is too high or both! All instrumentalists should avoid raising or dropping wrists.

Jaw Pain

Among musicians, violinists and violists are four times more likely to have jaw pain. Our term violin “hold” implies a static, rigid grabbing of the instrument. Be wary of the fact that you may use more pressure holding your instrument when you are trying hard or are nervous. Forty-seven percent of chin string players have jaw pain due to the fact that the joint is subject to years of pressure on the chin rest side. Those who begin music at very young ages may even develop altered facial symmetry. Wind and brass players may clench their teeth, and any of us may grind our teeth
overnight.
The two hinges at either side of your face are responsible for opening and closing your mouth, and when they are not working properly, they can cause tissue damage and pain.
Temporomandibular joint dysfunction (TMJ) is surprisingly common in the general population as well as in musicians, but not all jaw pain is TMJ. Muscular pain is actually more common from compulsive clenching or grinding of teeth. Compulsive chewing can bring on jaw problems, but more often stress is the precipitating factor in those individuals who grind their teeth and who clench jaw muscles tightly.
This “pain in the jaw” can result in headaches, hearing loss and ear pain, blurred vision, backaches, jaw clicking, sore and tight jaws, facial pain and worn teeth.
Diagnosis is vital. A good specialist will be able to see wear and tear in your teeth, and will likely take a full history before attempting diagnosis. Proceed first with gentle remedies. Jaw exercises, massage, acupuncture, biofeedback, stress management, cold packs for discomfort, and technique modification can all work.
To avoid aggravating the condition, eat softer foods and chew smaller pieces. Keep your neck and jaw aligned when you are getting ready to go to sleep. Restrict activities that involve opening your mouth wide or clenching your teeth. When your mouth is relaxed, your teeth shouldn’t be touching.

Keep Lips Together and Teeth Apart

Analyze your technique. Some teachers advise sticking your tongue out between your teeth when you are playing to prevent jaw clenching, or placing a small chunk of carrot between the back molars. If you crunch, you are clenching!
Refit chin rests and shoulder pads to eliminate “grabbing” your instrument. All instrumentalists, make sure you are not clenching or misaligning your jaw while playing. Relax your jaw and mouth as often as possible during rests, and take frequent breaks. Practice doing a “fish face” or an “air mouthwash” to aid in release.
Above all, injury prevention is a matter of paying attention to changes, in addition to carefully examining technique and posture.
Be vigilant concerning any abrupt change in technique. Are you trying a new bow or instrument that is bigger, heavier, or balanced differently from what you’re accustomed to? Are the strings too high off the fingerboard? Is the instrument set up in such a way that it is “resistant”?
Monitor sudden increases in playing time and/or intensity.
Are you attending a summer festival or music camp, or preparing for an audition or competition where you have a sudden increase in the amount and intensity of practice? Do you think you must play every day or you’ll lose your edge? Quite the contrary. You are probably overusing your muscles by never giving them a break. Or you might suffer from the opposite problem. Are you a busy parent who juggles practicing with family duties between orchestra services, showing up to play without adequate preparation or warm-up? In this case, you tax your muscles with difficult repertoire without really being in shape for it.
Make sure you avoid “marathon” practice sessions. Take a ten-minute break per hour of practice, and take time to lower arms, wiggle and stretch frequently. Listen to your body and stop playing if you feel pain.
Above all, protect your hearing. IPods, headphones, the sound of your own instrument, especially in small reverberant spaces, and stage placement can damage your hearing. Use hearing protection.
If you are concerned about your injury risk, try the following Injury Susceptibility Quiz. If your answer to many of the questions is Yes, you may be putting yourself at risk for an injury. Overuse injuries can creep up on you.

INJURY SUSCEPTIBILITY QUIZ

• 1. Does your teacher have an intense teaching style?
• 2. Is your playing style intense, emotional, macho?
• 3. Do you have a predilection for difficult, pyrotechnical, challenging, loud repertoire?
• 4. Do you love to slam your bow or slap your fingers into the strings or keys?
• 5. Do you practice mostly at the forte dynamic range?
• 6. Do you love chop-busting, high range exercises?
• 7. Do you squeeze your instrument while holding it?
• 8. Do you jam the keys down even when playing softly?
• 9. Do you “lose track of time” when practicing?
• 10. Do you never say no?
• 11. Do you clench your jaw or grit your teeth?
• 12. Do you schedule “back to back” rehearsals, gigs and performances?
• 13. Do you play in spite of fatigue and pain?
• 14. Do you fling your fingers off strings or keys?
• 15. Do you grip your bow tightly or grab your fingerboard or squeeze it?
• 16. Do you play a very large, heavy or very resistant instrument?
• 17. Do you play with a heavy bow, keep your strings high, or use a worn-out, ill-fitting chin rest?
• 18. Do you stretch to reach notes or keys?
• 19. Do you hold fingers uplifted and/or curled?
• 20. Do you hold stretches, double stops, or chords down?
• 21. Do you snap your elbow when changing from downbow to upbow?
• 22. Are you a tense, stressed person?
• 23. Are you depressed?
• 24. Do you neglect to warm up?Do you sleep poorly?
• 25. Are you physically inactive?
• 26. Are you overweight?
• 27. Do you consume more than two cups of caffeinated beverages a day?
• 28. Do you take drugs or drink more than a moderate amount of alcohol?

Playing an instrument should not be reduced to drudgery and struggle. The goal, after all, is to experience a sense of elation of playing music. It is difficult, if not impossible, to feel inspiration and passion while playing in pain.