The Flutists’ Pain Points

 

Ask almost any flutist that has pain brought on by playing, and odds are they will mention one of these sites as giving them trouble: wrist, upper back (between shoulder blades), shoulder area or lower back. Sometimes the problem is that the pain is in ALL of these sites.

Studies have been done, but the results are inconclusive as to the results of what causes pain. A study I read recently studied the “History of Playing-related Pain in 330 University Freshman Music Students”. The interesting point is that MOST of the students had pain brought on by playing. The frustrating point was that the study was inconclusive as to the cause of the pain.

I have my own hypothesis, however, because this study did not cover my area of expertise: strength training. This is what the study found:

  • More students did than did not exercise, but pain occurred in 79% of the exercisers and in only 76% of the sedentary. Data were collected though not analyzed regarding exercise type; jogging appeared to be a favorite, as was the use of a variety of exercise machines
  • Most of the pain problems reported by instrumentalists are associated with the musculoskeletal system
  • Several factors have played into the lack of regular exercise for musicians. First, those who start their instruments early in life…often have been warned of the potential injury that might befall especially their hands and fingers by participation in athletics. This avoidance behavior becomes habit as they grow older.
  • There apppears to be an association between poor conditioning and musculoskeletal complaints, and vice versa; those who do have a regular exercise routine appear more resilient.
  • When asked about “regular exercise” …our definition for inclusion here was exercise of at least two times per week for a minimum of 30 minutes. We did not differentiate between exercise modes, but just from casual scanning of the data, jogging was by far the most frequent activity, followed by some kind of machine and/or light weights and biking. A minority did heavy resistance weight training, swimming, soccer and/or basketball.

It is GLARINGLY obvious to me what could possibly be the cause of so many musician’s pain, here, but this was not covered by the researchers.

  1. The type of stretching done, is probably out-dated, static stretching, which has been shown to be more detrimental than helpful
  2. Jogging is a favorite activity….this does NOTHING to help weak muscles. If you play an instrument held in front of your body (aren’t they all?) then your body is forced to compensate after the primary muscles holding up the instrument fatigue. Thus leading to pain.
  3. The MINORITY did heavy resistance training and soccer, swimming and basketball – sports that require a high degree of movement.

Can you see the pattern here?

So getting back to the flutists’ pain points

What are the points of chief complaint?  From what I have heard (though if you have another spot, please leave a comment below!) these are the most common

  • wrist
  • upper back
  • shoulder
  • lower back

With the exception of the wrist, the other three points are located on what we call the “posterior chain”  This is the back half of the body, responsible for a lot of pulling movements and fighting against the pushing movement of the front of the body, including keeping the body upright.  If your posterior chain muscles are weak, it causes them to stretch.

Example:

You sit all day, in rehearsals, driving, typing, practicing.  You probably slouch, meaning your chest comes forward, your abdomen caves in and your back rounds.  You are not balanced on your sit bones.  Your shoulders round forward.  Your head protrudes.

What does this lead to?

Try taking that posture for awhile and I bet the answer will be:

  • my neck hurts
  • my upper back hurts
  • my hips hurt
  • basically, everything on the back half of my body HURTS!

Can you see how this  posture, practiced day in and day out is compounded with holding a heavy instrument (or maybe your instrument isn’t heavy but after several hours of playing it becomes heavy to you) can wreak havoc on your body?

Solutions!!!!

The part you’ve been waiting for!  You can see where the problem lies, by now, I hope.  Weak posterior chain can equal pain.  What to do?  Strengthen it!  Let’s take this on a spot by spot basis.

 

Wrist

If your wrist hurts, there can be several causes, some of which may not have anything to do with your wrist, but  may actually be a symptom of poor upper body posture, shoulder position, etc.  Assuming you play an instrument that puts your wrist in somewhat of a contorted position (flute, guitar, violin, etc.) there are some stretches you can do.  Hold each for a count of 10, and follow with movement.  It is very important that after you do a static stretch (a stretch you hold without moving) that you follow that with a dynamic stretch (a stretch that involves movement).

                                                                             

These are stretches and of course there are exercises you can do to increase your wrist/grip strength.  However, I’m not sure that that is necessary, as my guess is that the reason the wrists hurt has more to do with being tight and needing to be stretched due to being in an awkward position for long lengths of time, rather than being weak.  However, grip strength is important when it comes to lifting weights.  Diesel Crew has a lot of information on improving grip strength.

 

Upper Back/Shoulder

This area could take all day to address, and I have in two posts and a guest post by Dr. Perry.  For detailed information see Shoulder Pain Part 1, Shoulder Pain Part 2 – What to Do About it, and Dr. Perry’s Post: Shoulder Pain Secret.

The chief culprits of pain are the rhomboids (the muscles in between your shoulder blades that work to pull them together), lower traps (pull shoulder blades back and down) and rotator cuff muscles.  When you lean forward with a rounded posture, or have your arms extended in front of you for a long time, these muscles that do the pulling in your upper back get stretched the opposite way and get kinda angry about it.  They are designed to pull the shoulder blades back, but if you do not strengthen these muscles, if they do not get used the way they were intended.  You get pain.

I think this is the biggest problem area among musicians and the most overlooked!

Strengthen your rhomboids and upper back by doing pulling movements and see if your pain doesn’t improve, not to mention your posture!

My favorite exercises are:

Lat Pulldowns/Pull ups, any type of rows (inverted, seated, barbell or dumbbell) and exercises for the rotator cuff: soup can pours, prone lower trap raises and wall slides.  You can see all three of the rotator cuff exercises in Shoulder Pain Part 2.

Before doing any of these exercises, however, it’s not a bad idea to stretch the muscles that are tight, before strengthening the muscles that are weak. That’s another post for another day. :)

Lat pull downs/Pull ups.

     Good form                       BAD FORM!!!

(Coaching cues – keep spine neutral – curve in lower back, no leaning backwards, and bring shoulder blades down)

The big thing to remember here is to that before and DURING the movement, is to let your shoulder blades go through their full range of motion and lead the motion with pulling them back and down.

Huh?

That means that when your arms are as far away from you as they can be, let your shoulder blades float outward to the side of your body and when you go to pull the bar down think of squeezing the bottom of your shoulder blades together first to bring your blades down, and then your elbows and arms follow to complete the movement.  This may cause you to not use as much weight as you would like, but so what?  If you use more weight than you can with good form, what are you really accomplishing?  THAT’S where you get into more pain and injury.  If you see someone swinging back and forth and flinging the weight up and down (or YOU are that person) then you know you are asking for injury and are performing the movement incorrectly.

Don’t waste your time.  Take your ego out of it (and don’t pay attention to the people around you – most people in the gym perform exercises with incorrect form, so don’t take your cues from them) and discover what weight you can lift correctly.  You will reap benefits much faster!

Inverted Row

Coaching cues: keep body “straight”, brace your abs and squeeze your butt, bring shoulder blades back and down and let your arms follow. Think of leading the motion by squeezing your shoulder blades together first, not that it’s an arm movement.

Coaching cues: sit tall, brace lower abs and pull belly button in towards spine, pull shoulder blades back, down and together, keep neutral arch in back, do NOT round your back when reaching for weight or pulling forward.  Let your shoulder blades “float” to the outside of your body when letting the weight go back.

Lower Back

If your lower back hurts, ask yourself how much you sit.  If the answer is “a lot”, you may have found your problem.  When you sit, your hips “flex”, this means that the knees come towards the body by means of the hip flexors   The hip flexors are pictured here and I know the Alexander Technique teachers will jump all over the psoas, as they should! That’s where I first found out about this very important muscle.  You can see how it attaches to your leg AND your low back. When you sit, this muscle flexes, or shortens, which (especially if your abs are too strong – aka, don’t do situps or crunches!!!!) causes you to bend forward, this muscle pulls on your low back.  The muscles on your low back (Quadratus Lumborum and spinal erectors, etc.) get stretched, just like the upper back muscles.

Solution?

Stretch the tight muscles, strengthen the weak muscles.  In this case, stretch the hip flexors, strengthen the low back muscles  and muscles of the core.  The CORE is actually made up of your entire torso and if you want an EXCELLENT book on strengthening the core in the non-traditional way (there is not a single “ab” exercise in this book!) I HIGHLY recommend getting New Rules of Lifting for Abs. 

I’m just finishing up this book myself and not only has it improved my posture, it has improved my balance, core strength and overall body strength.  I can lift heavier weights than I have in a long time and I have better posterior chain activation as well!

There are WAY too many exercises to list here for strengthening the core and lower back, and in fact, if you want more information on that, I cannot recommend anything here safely, which is why I recommend hiring a personal trainer to help you do these exercises, because done incorrectly you can cause more pain or even injury to yourself.

As for stretching the hip flexors, I have some great ones.

You can do this standing as well.  Make sure when you do this stretch, you lean backwards with your torso until you feel a stretch in the front of your hip and SQUEEZE your put on the stretched side.  When you stretch the hip flexor, you want to activate the opposing posterior chain muscle, in this case, the glutes.

This exercise is one you can do during rehearsals, while typing, or while lying down.  It will stretch your piriformis muscle (the angry little muscle in your butt that gets stretched out when you sit for too long).  I recommend doing this lying down: take the chair out of the picture and put the person on his back.  Grab the vertical leg and pull it towards the chest.  The horizontal leg (the one that is bent across the other) will feel a stretch in that glute and hip.

 

A good stretch for the psoas is this stretch:

Lie on the edge of a bed, bench or table and pull one leg towards your chest.  The other leg should dangle off the edge of the table.  DO NOT do this exercise if your doctor has told you not to or you have major back pain.  Check with your doctor first if you have concerns.  When doing this stretch, you should feel a deep pulling feeling in your abdomen, that is difficult to identify.  This is your psoas.  Hold for a count of 20-30, and switch sides.

You can also do this on the floor to test for hip tightness.  Lie flat on the floor just like in this picture.  If your lower back comes off the floor and rounds, it can be a sign of hip flexor tightness.

What are some exercises I need to NOT do?

As you can see in this post, training the posterior chain is of utmost importance.  Therefore, training the frontal chain, is not as important.  If you have muscular imbalances, you do not want to add any more strength to those muscles.  The opposite of the muscles covered in this post would be: chest, quads, biceps.

Exercises I do not recommend if you are in pain:

Chest presses, bench presses, cable flyes (basically any chest pushing exercise), crunches, situps, any kind of oblique twisting ab exercise,  leg extension machine.

Other GOOD exercises to include would be exercises that train the entire body:

  • Pushups
  • Deadlifts
  • Squats
  • Rows

Make sure you perform these exercises with permission from your doctor and under the supervision of a properly certified personal trainer.  If you have any kind of health condition, check with your doctor first.

Identfying Shoulder Pain Part 2 – What to Do About It

Additional Disclaimer

Before I continue this post, I would once again like to state that I am not a licensed medical professional and this post is not intended to treat, diagnose or cure any medical injury, disease, cause, condition or ailment.  If you suffer from any type of pain you should seek the cousel of a qualified medical professional.  A partial list of these professionals is located in the second half of the first post.  The information in this blog is given with the intent to educate but not diagnose and I am not liable and do not claim responsibility for any emotional or physical problems that may occur directly or indirectly from the content of this blog.

Now that you know what your own anatomy looks like and how it functions (if you don’t, make sure you read Part 1 first!):

What are some things I can do on my own to address my shoulder pain?

Allowing that you do not have an injury and we are dealing with muscular issues, there are several things you can do.  Again, before attempting any type of self-diagnosis or treatment, if you have pain you should seek out the advice of a qualified medical professional.

Stretches

To even start to begin to correct this, we first have to stretch out the antagonists (chest and front delts) before we can begin to strengthen the posterior chain (rhomboids, etc.).  You can see all these stretches in a previous post here: Stretching Adequately Before/During/After Playing

  1. Doorway or Wall Chest Stretch – will stretch your chest
  2. Scapular Wall Slides – these will activate your lower traps and rhomboids
  3. Arm Circles – be gentle on these
  4. Upper Trap/Levator Scapulae Stretch

    With this exercise you can perform it standing and your non-moving arm can be extended straight down with thumb pointing towards the ceiling for a greater stretch

 Foam Rolling/Self-Myofascial Release

A foam roller cannot take the place of a massage therapist, but if you cannot afford to go, this is your best option. You can cover a wider area with the foam roller, and get more specific with a tennis ball, hitting your own trigger points.  Remember, pain is not necessarily at the point of discomfort, it can be “referred”  from another part of the body.  When you press on a trigger point, you may feel that  pain shoot through the body to where you felt discomfort.  Dr. Perry gives more examples of this in his guest blog post Shoulder Pain Secrets.

Guidelines for foam rolling: roll over the muscle to find the most tender spot.  Once you find it, lay on it for 20-30 seconds until the muscle begins to relax.  Then, roll the entire area.  Repeat if necessary.


Tennis Ball Work

This video from Synergy Athletics tells some of the do’s and don’ts of using a tennis ball. Actual usage is towards the end.

This is a really good description of how to use the tennis ball on trigger points in not only the shoulder but the neck.  As I have just recently found out from Stop Chasing Pain’s Dr. Perry, if you have shoulder pain, there is a good chance your scalences or SCM (or other deep neck flexors) could be too tight, as well.

In any case, this next description of how to use a tennis ball, I actually found on a message board.  I’m sorry that I don’t know to whom I need to give credit for this!
Use the following diagram for an idea of what muscles are being treated.

Image courtesy of http://www.sports-injury-info.com/im…er-muscles.jpg

So here we go.

This is how you treat your (upper) trapezoid muscles.

This is how you treat your rhomboids (down the trapezoids and between the shoulder blades) as well as your infraspinatus. You must squat down to apply pressure. You won’t get enough pressure on the ball if your legs are straight.

This is how you treat your side deltoids (you can do the same with the anterior and posterior deltoids). Put your bodyweight behind it.

This is how you treat the clavicular head of your pectoralis (the upper part of your chest):

Now, this is the tricky part, the side of your neck, the sternocleidomastoid muscle (the one that usually pulls to one side screwing things up.)

For this to work, you need to use the corner of a wall. Furthermore, you need to really drive your bodyweight. This is one of the strongest muscles. Don’t kill it but work on it.


Wanna Free E-Book?

You can’t get much better than this: Mike Robertson put out a  free e-book on Self-Myofascial Release using foam rollers, The Stick AND tennis balls.  It starts with lower body and the upper body tutorials are towards the end, but if you have a foam roller and a tennis ball, you can really work yourself all over with the help of this book. There is even a section on helping the wrist flexors!

Self-Myofascial Release Manual

Strengthening Exercises

As we have just learned, muscles of the upper back tend to become weak and stretched, due to hours of doing things with our arms in front of us, which leads to tight pectorals

Serratus anterior muscle

Image via Wikipedia

(and Serratus Anterior, I forgot to mention).  This means these muscles need to be strengthened and one of the absolute best ways of doing this is resistance training.

Any kind of motion that counter acts the pushing motion (which is what your tight chest muscles are already doing) will help.

These motions are primarily any type of rowing or pulling motion.  If you think of these exercises in planes of motion, you have two choices: horizontal pulling and vertical pulling.

Horizontal pulling would be things like seated cable rows, 1-arm dumbbell rows, barbell rows, T-bar rows, X-cable crossovers, Face Pulls, etc.
Vertical pulling motions would be things like Pullups, lat pull downs, althernating pulldowns, chin ups, etc.

All of these exercises will be helpful to strengthening the back muscles.  The biggest thing to remember when performing these exercises is to get the form right.  What do you need to remember?  Retract and depress your shoulder blades and keep them that way THROUGHOUT the movement.  This means that when you are doing any kind of pulling motion, when you let your arms extend back, they should not be able to full extend because you still have the bottom of your shoulder blades pinched together.  This activates your rhomboids and lower traps and allows them to do their proper job of stabilizing your shoulder girdle.

For these movements you will have to have equipment of some kind, be it a pullup bar, bands or dumbbells, and that is really the only limiting factors of these exercises.  I have some great links to the kinds of bands I use on my website at http://fluteangel.net/links.htm  if you want to go pick up some.  They are very inexpensive and portable and can come in varying strengths.

Prone Lower Trap Raises

These have to be one of my absolute favorite exercises I had never heard of.  They  look deceptively easy until you try to do them and realize that just lifting your arms without any weight is heavy enough!  In fact, this is such a good idea, I might just do a blog post all about activating the lower traps…

Here is a version you can do at home if you don’t have a bench:

From Neanderthal No More By Eric Cressey and Mike Robertson

Ideally, this exercise is performed face-down with your chest-supported on an elevated flat bench (i.e. longer legs, so that you’re higher off the ground). However, if you don’t have access to such a bench, you can do it bent-over; just make sure that your upper body remains parallel to the floor at all times (no cheating!)

Hold a dumbbell in one hand with a supinated group (the thumb points up at the top of the movement). Begin with the arm dangling below you on the bench. Horizontally adduct (think reverse fly) your arm while maintaining the thumb-up position. At the top, your arm should be at the 9 (left) or 3 (right) positions, and the upper arm and torso should form a 90-degree angle. Throughout the movement, concentrate on retracting the scapulae while keeping it tight to the rib cage (no winging).

Rotator Cuff Exercises

There are an awful lot of these exercises, however, one thing to make sure you realize when performing these exercises is that it’s not about how much weight you can lift.  The SITS muscles are small and if they are causing you pain, they may not only be weak, they areprobably tight and stretched which means you need to be even MORE careful.  1-3 lb. dumbbells will be PLENTLY for these exercises.

The two you probably recognize are internal and external rotation exercises.  Stand perpendicular to a pole with a band attached.  While keeping your elbow tucked in closely to your side rotate your arm inward, pulling the band and then slowly back.  Turn the other way and now you are pulling the band across your body.

Soup Can Pours

In a standing position, start with your right arm halfway between the front and side of your body, thumb down. (You may need to raise your left arm for balance.) Raise your right arm until almost level (about a 45° angle). (Hint: This is like emptying a can.) Don’t lift beyond the point of pain. Slowly lower your arm. Repeat the exercise until your arm is tired. Then do the exercise with your left arm.

Exercise 4

Preventative Measures

Gerald Klickstein’s book The Musician’s Way: A Guide to Practice, Performance and Wellness is an excellent book on just those subjects.  In Chapters 12 and 13 (and reposted on the blog) he mentions 12 Habits of Healthy Musicians:

The Twelve Habits of Healthy Musicians by Gerald Klickstein
1.  Increase playing or singing time gradually
2.  Limit repetition
3.  Regulate hand- or voice-intensive tasks
4.  Manage your workload
5.  Warm up and cool down
6.  Minimize tension
7.  Take breaks
8.  Heed warning signs
9.  Take charge of anxiety
10. Keep fit and strong
11. Conserve your hearing
12. Care for your voice

The Musician’s Way specifies ways in which you can incorporate these twelve habits into your lifestyle. Here are a few highlights:

  • #1: To avert overuse injuries, restrict any increase in your total playing or singing time to a maximum of 10-20% per week (p. 12).
  • #4: Respect your physical limits and ask a mentor for advice before you take on an overload of duties (p. 243).
  • #5: Pages 37-39 present a six-step process for warming up thoroughly and efficiently.
  • #6: Two sections in Chapter 13 – “Balanced Sitting and Standing” & “Meeting Your Instrument” – depict how musicians can form easeful habits. Forty-one photos are included.
  • #7: In solo practice, play or sing no more than 25 minutes before pausing for a 5-minute respite. The Musician’s Way itemizes six restorative movements that help to invigorate breaks (p. 75-82).
  • #8: Injury symptoms can be subtle, as are the social issues that come into play when unwell musicians who are expected to perform need to rest instead. Pages 237-241 untangle these topics.
  • #9: Anxiety doesn’t just scuttle musicians on stage but also impels some to overpractice to the point of injury. Strategies to neutralize anxiety interweave throughout The Musician’s Way and come to the fore in Chapter 7, “Unmasking Performance Anxiety.”
  • #10: Music making requires mental, physical, and emotional vigor. Healthy musicians, therefore, mind their nurtrition, rest, exercise, and other self-care needs much like top athletes (p. 245-246).
  • #11: Strategies that thwart music-induced hearing loss are summarized in my post “Hear today. Hear tomorrow” and fleshed out on pages 277-291.
  • #12: A section titled “Voice Care” encapsulates vocal hygiene under seven headings, the first of which is ‘Drink plenty of water’ (p. 268-277).

Postural Considerations

As flutists, a good many of us suffer from poor posture, made worse by long hours of playing without being in tune with our bodies.  If you are “stuck in your head” and not paying much attention to your body by being so focused on the music, you may notice that when you finally stop playing, you are sore, tight, hurting, and in terrible posture – slouched to the side, front, or otherwise not upright.

Besides understanding your individual body map and taking the time to be aware of your posture WHILE playing, let me propose a postural alteration.  Many of you may do this, but many of you may not:

When playing, take note of your arm position.  Do your elbows “fly” away from your body?  If so, this puts tremendous stress on the little muscles of the rotator cuff, which are not well equipped to deal with this type of endurance activity.  Let your arms hang from the flute, keeping the elbows closer to the body and also making sure the left arm is really under the flute.  When you sit, make sure you are BALANCED on your sit-bones with your feet FLAT on the floor.   This should help keep you in the proper position while leaving your deltoids and biceps to do the hard work of fighting gravity instead of your little rotator cuff muscles.

Dr. Susan Fain has some great information in her dissertation, and I highly recommend you check it out!  You can also hear the both of us at the National Flute Association Convention in Charlotte this August speaking with Lea Pearson and Karen Lonsdale about pain prevention.

Additional Resources and Articles

By the way, there is an EXCELLENT 5 – article series called Neanderthal No More: Fixing Your Caveman Posture by Eric Cressey and Mike Robertson over at T-Nation.   It can be a bit advanced for some, but if you are looking for a lot of information by people who know what they are doing and you wouldn’t mind a full week’s workout laid out for you, I’d check it out.  Not only does it have a full description of anatomy, it delves into body awareness by asking you to check out your own posture in different ways and then testing it to examine your own posture and movement patterns.  In part 3 they give client analysis – see if you can determine what’s “wrong” with these guys. :)

Please, tell me if this addresses your shoulder pain and if you found this helpful, leave a comment below.  Let us know what pain you are dealing with, what has worked for you and if you have anything to add to the post, let’s hear it!  Look for some guest blog posts dealing more with these issues, soon!

And feel free to link your own articles to this blog, down in the comments section!

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