It’s hour two in your daily practice routine. You’re starting to feel dull, achy pain. Maybe it’s in your low back, shoulder region, or your neck. You’re getting shifty – craving a change in position or a stretch, but you must keep going. Your performance is just around the corner.
Let’s talk about a few ways to lessen these nagging aches and pains. Some strategies are applicable for short-term relief. Some will require a longer-term effort to see results. Here’s what current performance arts literature tells us is crucial to injury management and prevention:
Alter your practice routine and include rest.
First and foremost, education regarding safe and realistic practice routines incorporating periods of rest will help to prevent many injuries from occurring (especially tendinitis and postural pain).1
When I was working on my bachelor’s degree, my daily practice goal was 4-6 hours of practice per day, 5 days a week. My strategy was to lock myself in a practice room for that entire time and play solidly through. Knowing what I know now as a PT, I don’t practice that way anymore.
Instead of practicing in large blocks, practice in shorter chunks throughout the day. This will give your body time to rest, repair, and regenerate which will help reduce likelihood of overloading tendons and muscles. In addition, this gives the body time for mental practice and processing of the motor skill you are learning (playing an instrument!), which has been shown to positively affect skill acquisition.2 Practicing this way reduces risk of overuse injury and helps improve learning and performance. This is a win-win for any musician.
Warm up and cool down before and after playing.
Warming up before playing will improve blood flow and mobility which may lead to an improvement in performance immediately following warm up.3 The general purpose of a pre-exercise warm-up is to increase muscle and tendon suppleness, to stimulate blood flow to the periphery, to increase muscle temperature, and to enhance free, coordinated movement.4
In the athletic population there is mounting evidence to support dynamic and/or sport-specific warmups rather than static stretching to improve performance. In fact, sprinters who perform static stretching before running can actually impede athletic performance.5 This may or may not be entirely relevant to musicians because the movements we perform are less explosive than sprinting, but I can see crossover in our finger tendons’ ability to react quickly and efficiently within playing that requires speed and dexterity. A warmer tendon will perform better than a cold, stretched out tendon.
There is other evidence that supports combining dynamic activity-specific warmups with static stretching. The claim is that the dynamic warm up improves power and performance while the static stretching improves flexibility, and no detrimental effects in performance were found when both were included as part of the warm-up.6
What is a dynamic warmup? This means that instead of doing long duration static stretching (30-second holds), you go through a series of active stretches and movements relevant to your instrument to increase both tissue temperature and flexibility.
As far as cool down goes, static stretching is perfectly acceptable at this time because improved performance is no longer the goal, but rather increasing tissue comfort and alleviating feelings of dull, muscle ache associated with prolonged practice or performance and maintaining static positions for long periods of time. This may include stretches to the wrist, elbow, and shoulder, but also may incorporate neck or spinal mobility stretches to alleviate postural pain from sitting or standing.
Build cardiovascular exercise into your weekly routine.
It is important to incorporate cardiovascular exercise into your weekly routines to improve general stress and wellbeing as well as provide adequate blood flow needed for tissue repair and regeneration.1 I know, I know, you’re already practicing many hours a day, how are you going to find the time for cardio? Try not to think of cardio as separate from practicing your instrument. It is a PART of your holistic practice regimen.
Being a musician requires athleticism. Being athletic is defined as being physically strong, fit, and active. How many athletes do you know who don’t do some form of cardio? The American College of Sport Medicine (ACSM) recommends all people get 150 minutes of moderate intensity exercise per week.7 It does not matter how you split up the time, you just need to get it in. Try 30-minutes, 5 days a week. Do it in bouts of 10 minutes 3 times a day if you want. Choose any activity where you are increasing your heart rate, which improves your body’s ability to deliver oxygen to your tissues. Walk briskly, hike, ride your bike to and from work or school, do an at-home cardio YouTube video (I like www.fitnessblender.com), go swimming, play ultimate Frisbee … you get the idea. It doesn’t matter what it is, but it should be something that sparks joy (#mariekondo) otherwise you’ll throw it out.
What’s moderate intensity? It’s about 60-80 percent of your maximum heart rate. The generic formula many people use for maximum heart rate is: Heart Rate Maximum = 220 – Age
Here’s an example for a 34-year-old: 220-34 = 186. That is the maximum heart rate a 34-year-old person should get up to during exercise. Moderate intensity for this person would be somewhere between 112-149 beats per minute.
Don’t want to do math? Fine. When you’re doing cardio, moderate intensity starts right around the point where you start to feel like you can’t breathe through your nose anymore and it’s starting to get difficult to speak a full sentence without taking a breath.
Cross train to build strength, endurance, and flexibility.
Additionally, performing arts research supports incorporation of cross training into our routines, which may include a combination of strength, conditioning, and flexibility activities that all will help to improve your stamina and reduce pain while playing.1
What should you be strengthening? It depends on your instrument. However, in general, it should include exercises to improve your postural endurance, including your core, your back muscles (particularly your paraspinals, middle and lower trapezius, rhomboids, serratus anterior), and your deep neck muscles. Postural muscles are utilized mostly for prolonged positions that require muscular endurance – the ability to maintain a contraction at a low load for a long period of time. As such, it may be beneficial to strengthen these muscles with isometric exercises (sustained holds) or strengthening exercises that are performed with low resistance (weight) and high repetitions (15-20 if not greater per set).
If you are a vocalist or wind instrumentalist, incorporate exercises to improve diaphragmatic strength, endurance, and function. If you are a string player, wind instrument player, percussionist, or pianist, you should include shoulder, elbow, wrist, and hand specific strengthening. String players need a combination of upper body strengthening (heavier resistance for few repetitions), endurance (see above), and power (combination of strength and speed, i.e. quick, explosive exercises especially for elbow wrist, and fingers).
Eat healthy and drink plenty of water.
Understanding the role of nutrition and hydration can help to reduce injury risk and may facilitate healing once injury has occurred according to research in performing arts medicine and research of tendinopathies.1,8 One component of tendon injuries is inadequate nutrition, which prolongs the inflammatory response of the body. That might be one reason why that stubborn tennis elbow isn’t getting better. Water improves the elasticity of tendons and helps tendons (and nerves, for that matter) slide and glide nicely in their sheaths. Certain macronutrients (carbohydrates, fats) provide sources of energy to cells for metabolism (all the cell stuff going on in your body that keeps you alive) and proteins are the building blocks for all of our cells. Micronutrients, such as vitamins and minerals, are important for cellular expression and metabolism and deficiencies or surpluses can lead to tendon injury.8 For example, in one study, 80 percent of people undergoing surgical rotator cuff repair were Vitamin D deficient.9 Takeaway: eat well, hurt less.
Make adjustments to your instrument’s accessories.
Modifications or adjustments to our instruments or their accessories, such as chin rest or shoulder rest, straps, etc., may also help reduce the effects of or prevent injury. This may reduce risk of getting a pinched nerve or postural pain.
Speaking as a violinist, shoulder rests come in all shapes and sizes and there is no one-size-fits-all approach. A shoulder rest’s most important function is to reduce tension by improving your playing ergonomics. It should be appropriately adjusted to the height of your neck and the anatomy of your collarbone and shoulder region, which includes modifications to the tilt and the angle it is placed at on the violin or viola. It should be adjusted so you can keep your neck in as little left rotation and left side bend as possible. In general, your head should be stacked directly over your neck, regardless of rotation, to maintain a state of balance and reduce risk of injury or postural pain during playing. Additional considerations include modifications to your chin rest which are dependent on jaw anatomy – whether you have a sharp angled jaw or a softer jawline – and the length of your bow arm. Generally, side-mounted chin rests work best for players with long necks and long arms. Center-mounted chin rests work best for players with shorter bow arms.
Set your practice environment up ergonomically.
While considering making instrument adjustments, it is important to also fix your practice environment. Improving the ergonomics of a practice or performance space can greatly improve body mechanics during playing, thus reducing injury risk and/or symptoms. This includes chair type, height, and position relative to your music stand if using one.
In general, your chair should be such that your feet may rest flat on the floor and your knees are slightly lower than your hips. Also consider music stand height and distance. The top of the stand should be at approximately eyebrow height (or a little lower), so your gaze is slightly below horizontal. The stand should be about 2 feet away from your face. Make sure you are up to date on your eye exams to ensure you don’t lean forward or squint to see small print during practice or performance. One caveat is to consider your playing setting. It may be acceptable to lower your stand slightly during orchestral or similar performances to ensure you can see the conductor. For home practice purposes, my earlier recommendations are preferred. Also consider your chair position in relation to your stand. Rather than moving your body on top of a fixed chair, move your chair so you are positioned with your line of sight perpendicular to your music. This may vary slightly when sharing a stand with another player.
Manage your stress.
Finally, we must have techniques to manage stress and reduce tension during playing to help improve the quality and efficiency of our playing while also reducing our risk of injury or pain.1 It’s no surprise to any of us that stress is a huge part of being a musician. Stress and performance anxiety are what led me to pursue a career outside of performing, so I cannot emphasize enough the importance of managing your stress. Not only does stress directly correlate to injury, but it also causes increased muscular tension, which can cause your performance to sound rigid and forced and also reduces the efficiency of your arms and fingers, making playing fast passages more difficult. We all know the mark of a good musician is one who makes playing sound effortless. How do they do that? They relax. They breathe. My recommendations include daily breath work, meditation, talk therapy, yoga, cardiovascular exercise, and spending time in nature.
So, in summary, get adequate rest, exercise, warm up/cool down, eat well, modify what you can control (practice routine, environment, ergonomics, instrument setup), and manage your stress! Happy playing!
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
Sattelmayer M, Elsig S, Hilfiker R, Baer G. A systematic review and meta-analysis of selected motor learning principles in physiotherapy and medical education. BMC Med Educ. 2016;16. doi:10.1186/s12909-016-0538-z
Fradkin AJ, Zazryn TR, Smoliga JM. Effects of Warming-up on Physical Performance: A Systematic Review With Meta-analysis. The Journal of Strength & Conditioning Research. 2010;24(1):140-148. doi:10.1519/JSC.0b013e3181c643a0
Smith CA. The warm-up procedure: to stretch or not to stretch. A brief review. J Orthop Sports Phys Ther. 1994;19(1):12-17. doi:10.2519/jospt.1918.104.22.168
Kistler BM, Walsh MS, Horn TS, Cox RH. The acute effects of static stretching on the sprint performance of collegiate men in the 60- and 100-m dash after a dynamic warm-up. J Strength Cond Res. 2010;24(9):2280-2284. doi:10.1519/JSC.0b013e3181e58dd7
Samson M, Button DC, Chaouachi A, Behm DG. Effects of Dynamic and Static Stretching Within General and Activity Specific Warm-Up Protocols. J Sports Sci Med. 2012;11(2):279-285.
- 2018. ACSM’s Guidelines For Exercise Testing And Prescription. Philadelphia: Wolters Kluwer.
- Loiacono C, Palermi S, Massa B, et al. Tendinopathy: Pathophysiology, Therapeutic Options, and Role of Nutraceutics. A Narrative Literature Review. Medicina (Kaunas). 2019;55(8). doi:10.3390/medicina55080447
- Scott A, Nordin C. Do Dietary Factors Influence Tendon Metabolism? In: Metabolic Influences on Risk for Tendon Disorders. Advances in Experimental Medicine and Biology. Springer, Cham; 2016:283-289. Accessed May 23, 2020. https://link.springer.com/chapter/10.1007/978-3-319-33943-6_27
About the Author/Specialist
Hope Hampton PT, DPT
Certified Manual Physical Therapist
Musician Rehabilitation Specialist
Hope is a Doctor of Physical Therapy with advanced training in orthopedics and manual therapy as well as a classically trained musician with more than 25 years of playing experience. Her primary instruments include violin, piano, and guitar. She utilizes her training and experience as a musician to develop specialized rehabilitation programs for injured musicians.