How to Navigate Music School with a Performance-Related Injury

by Francesca Leo. February 7, 2020.

Performance-related injuries have become a part of my identity as a music student.  I have suffered from severe tendonitis in my shoulders and forearms for as long as I have been playing my instrument, only truly understanding how to treat it and take better care of my body within the past few years.  In 2017, I conducted a study at the Bowling Green State University (BGSU) College of Musical Arts on the prevalence of performance-related injuries in collegiate music students.  An initial questionnaire was distributed to music students attending BGSU, and this questionnaire received 45 valid responses. The results of my study were alarming: 84% of participants experienced pain problems that interfered with their ability to play their instrument or sing at the level to which they were accustomed.  Additionally, 53% of students experienced the same pain they felt while they were playing or singing when they were away from their instruments. 

A majority of students (64%) experienced mild to moderate pain on average, and 73% of students experienced moderate to severe pain at its worst the week leading up to a major performance, competition or audition.  This statistic demonstrates a significant modest positive correlation between pain severity and music-related stress.  Students primarily experience the most pain in their shoulders, their right forearm, their wrists, their fingers, their mid to upper-back, and the left side of their neck, and most students described this pain they are experiencing as feeling sore or tight, with others describing feelings of cramping, aching, or weakness. When asked to describe their stress regarding classes, private lessons and ensemble preparation during the semester, participants made statements such as “I just worry that the pain I’m experiencing could end up causing long term issues in my music career”, “I feel that there are not enough hours in the day to accomplish everything that we are expected to accomplish and still be healthy.  Many teachers harp on wellness, but how can we be expected to take care of ourselves when we have 6 hours of practicing and 6 hours of homework that we are expected to complete?”, and “My hands and forearms get inflamed so I try to rest as much as I can. But the problem with that is I’m trying to rest myself to be able to keep playing, by not playing. The solution to me being able to play shouldn’t be to stop playing for a while.” 

Identifying the Injury

Results from similar studies reveal additional concerns of the prevalence of performance-related injuries.  Musculoskeletal pain is the most commonly reported type of pain [among musicians] (Stanek, Komes & Murdock, 2017), and 64-76% of professional orchestral musicians suffer some form of Repetitive Strain Injury so severe that it is affecting their performance abilities (Mitchell, 2017). Performance-related injuries can be especially detrimental to students under the pressure of coursework, weekly repertoire demands for private lessons and ensembles, and constant extremely high expectations.  The development of severe performance-related injuries early on in one’s career is alarming and can contribute to feelings of stress and worry that this injury may prevent them from pursuing a career in music in the future.  As performance-related injuries and performing arts health and wellness becomes more of a prominent conversation, our society is becoming more and more aware of just how many musicians this epidemic has been affecting. 

The first thing I advise all students experiencing prolonged pain or tension while playing is to seek immediate medical attention.  My first experience speaking with a medical professional about constant pain in my forearms while playing was at age 16 when I received my first official diagnosis of tendonitis.  At this time, my doctor’s only advice for treatment was to stop playing my flute if it hurt, or to rub a pain-relieving cream on the affected area.  As a stubborn teenager with a burning passion for music, quitting my instrument was simply not an option for me.  My injury worsened as a result and led me to a musculoskeletal doctor five years later when the chronic pain had spread to my neck and shoulders. My initial diagnosis of tendonitis was correct, but this time I learned that it was now affecting nearly my entire upper body.  

The most common performance-related injuries that musicians face are Repetitive Strain Injuries (RSI) and can manifest themselves in the form of tendonitis, carpal tunnel syndrome or bursitis.  All RSI’s are treatable, but I advise seeking medical attention as soon as you notice a persistent problem.  Tendonitis (Cleveland Clinic) is an inflammation of the tendons which is caused by repetitive movements of the fingers or hands and can be an acute or a chronic condition.  Tendonitis can become present in nearly any part of the body, with the most common areas being the elbow, shoulder, base of thumb and forearm for musicians. Symptoms include a gradual buildup or sudden and severe experience in pain at the site of the tendon or loss of movement in the shoulder.  Carpal Tunnel Syndrome (Cleveland Clinic) occurs when there is a prolonged increase in pressure along the median nerve within the wrist, and can be hereditary or caused by actions of high force (i.e. strumming, plucking strings, using mallets, pressing keys, etc.), extreme wrist motions (bowing/fingering string instruments, using mallets to play percussion instruments, etc.), or long-term use (multiple hours of practicing per day with few breaks). Symptoms include tingling sensations/pain in the fingers, decreased feeling, numbness, and difficulty handling objects.  Bursitis (Cleveland Clinic) is inflammation or irritation of the bursa, small sacs of fluid located between tissues in the shoulders, elbows, knees and feet.  Bursitis is often caused by repetitive motions and can be identified by a gradual build-up or sudden and severe experience of pain in these areas.   

Other injuries faced by musicians include TMJ Disorders (temporomandibular joint), Vocal Cord Lesions (nodes) and Thoracic Outlet Syndrome (Cleveland Clinic).  TMJ Disorder can be identified through symptoms such as clicking or popping sounds in the jaw, difficulty chewing and “lock jaw” sensations.  This is especially prevalent in wind players and can be caused by stress and grinding or clenching of the teeth as well. Vocal Cord Lesions primarily affect vocalists and is caused by repetitive overuse/misuse of the voice. Symptoms include loss of vocal range, hoarseness, vocal fatigue or loss of voice all together.  Thoracic Outlet Syndrome affects the lower neck and upper chest area and can be partially caused by repetitive arm or shoulder movement, pre-existing repetitive injuries, and poor posture. Symptoms include neck, shoulder and arm pain and numbness in these areas as well.  

While it is important to be able to identify the sensation and the exact areas of your pain, self-diagnosing is dangerous and may worsen your injury if you are not treating it correctly.  Before your appointment, be able to describe your pain (i.e. “pins and needles”, dull ache, soreness, sharp/shooting pain, weakness, numbness, tingling, etc.) and the severity on a scale of 1-10 both while you are playing your instrument and while you are away from your instrument. The more specifically you are able to identify your pain, the more accurate your doctor will be able to diagnose you and set you on the right path for treatment.  Be prepared to be persistent with your doctor if their only advice is to stop playing your instrument.  Explain to them that this is your profession and that it is really important to find a treatment plan that works for you and allows you to continue playing your instrument.

Seeking Cost and Time-Efficient Treatment

As a music student, you have little control over your own schedule and are likely paying thousands of dollars in tuition each semester. Taking care of a performance-related injury may seem impossible at first, especially if you have been told that it will require drastically reducing the time you are able to play your instrument each day.  We are taught to treat 6-8 hours of individual practice hours per day as the standard, when in reality most students only have time and energy for 3-4 hours maximum.  Instead of being taught how to make the most out of our time in the practice room, we are held to an impossible standard that makes us feel inadequate if we do not meet the demands of daily time limits.  With an average 16 credit-hour class schedule, extra-curricular activities, ensemble rehearsals and part-time jobs, any free time you have during the day is likely spent practicing and preparing for your weekly private lessons and rehearsals.  This rigorous schedule also leaves little time to work, which can be financially stressful for students that need to pay monthly rent and bills. Having an added financial stressor of professional medical treatment for a performance-related injury can steer many students away from getting the help they need.  

            My primary motivation for creating www.playingwithoutpain.com is to provide a free online web resource for students to find information on performance-related pain and injuries.  Many music school programs lack the funding to provide performing arts health and wellness resources to students, and this creates a lack of awareness and discussion about performance-related injuries as a result.  If you are currently experiencing pain when you play and it has been persistent, do not wait any longer to seek treatment. 

The first step is to find out if your school has an on-campus health center.  If so, call ahead of time and make sure that your insurance plan or tuition will cover appointment co-pay costs.  If you are asked to describe your pain or condition over the phone, explain that you are a musician and are experiencing pain related to muscle misuse from playing your instrument and that it is preventing you to do so. If your school does not have an on-campus health center with these kinds of resources, search musculoskeletal doctors in your area and call the office ahead of time or check online to be sure that your insurance plan is accepted.  Once you arrive at your appointment, be direct and as specific as possible about the type and area of the pain you are experiencing and emphasize that this pain is preventing you from playing your instrument comfortably which is your profession.  It can sometimes be difficult to get direct answers from doctors, and many will prescribe rest or a type of muscle cream as your treatment.  Ask specifically about your treatment options that will allow you to continue playing your instrument such as physical therapy, massage therapy, chiropractic care, etc.  All bodies are different, meaning that all performance-related injuries are different as well.  Work with your doctor to find the correct treatment plan for your injury, and don’t be afraid to ask about all of your options before leaving the appointment.   

            If you are prescribed with physical therapy, chiropractic care, or massage therapy, ask for a list of in-network treatment facilities that will work with your insurance plan in your area. Many of these treatment centers are flexible and willing to work around your schedule for regular appointments and often have extended hours to allow you to visit early in the morning or later in the evening.  Many of these treatment centers will require you to go 2-3 times a week at first depending on your injury.  Some school music programs also have a physical therapist on-campus and offer Alexander Technique classes.  It is highly recommended to take advantage of these resources if you are able, especially if you can enroll in an Alexander Technique course that is built into your tuition expenses.  As defined by www.alexandertechnique.com, Alexander Technique is “a method that works to change (movement) habits in our everyday activities. It is a simple and practical method for improving ease and freedom of movement, balance, support and coordination.”  This method is especially helpful in unlearning tension and improving ease in your playing which can be an essential step in injury recovery.  

Other treatment methods include the Feldenkrais method and body mapping which are similar in pedagogy to Alexander Technique.  Regular exercise is also a vital component of the injury recovery and prevention process, as it allows large muscles groups within your body to move and “reset”, relieving tension within smaller muscle groups as well and building strength to begin enduring longer periods of playing time.  Find an exercise routine that works for you, even if it is just going on a ten-minute brisk walk each day.  If you enjoy doing cardio exercise and are actively in recovery for an injury, try starting with an elliptical machine as this allows more fluid movements to your joints with less impact.  Weight training can also help injury prevention, but it is important to lift with the correct form to avoid injuring yourself further. Check out this article “Debunking Weightlifting Myths for the Musician” by Angela McCuiston for more information.

            Regardless of your recovery plan, it is important to be committed to the process and also transparent about your injury with your teachers and mentors.  Have an honest conversation in your private lesson about the pain you’ve been experiencing and your recovery process.  It is helpful for your mentors to know about your injury, and many will also be able to work with you on finding a healthier playing position. When mentors see potential in students, it is common for them to push these students to their limits to help them grow.  With a fear of letting your teacher down or losing out on opportunities, it is common for students to internalize their physical struggles and “push through” their injuries, only worsening the injuries and putting their long-term career at risk. Chances are, your mentor has experienced the same type of performance-related pain and likely has some advice on how to handle it as well.

Managing Your Time In and Out of the Practice Room

Now that you have started your recovery process, tuning into what your body needs during each practice session and developing efficient practice strategies to reduce your time in the practice room is essential.  Efficient practice is the act of working towards a set of goals with clear intentions and smart strategies to quickly bring music to performance-ready condition (Klickstein).  With limited time for individual practice and a significant amount of repertoire to learn by certain dates, it is important to develop a method of practicing that allows you to learn repertoire quickly and efficiently while maintaining attention to detail and musicality.  

When my performance-related injury was at its peak during my undergraduate degree, I had developed a bad habit of punishing myself in the practice room.  I used to practice for hours on end, taking no breaks and only stopping once I absolutely had to. This often resulted in running passages over and over again, making the same mistakes but refusing to stop playing until I heard a noticeable improvement.  I also had a tendency to “cram” practice, learning repertoire shortly before I had to play it for rehearsals and private lessons. When you are practicing under these types of conditions with heightened stress levels and a lack of time to adequately prepare, your body will hold a significant amount of tension while you’re playing as a reaction to this stress.  

Efficient practicing requires less time spent in the practice room, but a much higher level of concentration and focus.  After years of analyzing my tendencies in the practice room and researching performance-related injuries, I discovered that learning to practice efficiently is an incredibly important part of becoming a professional musician.  Developing efficient practicing habits is especially helpful if you are actively recovering from a performance-related injury and have limited time that your body is physically able to practice each day.  It is also helpful on days that you have long rehearsals or performances.  On these days, aim for extremely focused and shorter practice sessions to get the work done that you need without overworking your body.  

Now that we have defined “efficient practicing”, how do we begin to incorporate it into our daily routine?  I have attached an efficient practicing template to this article that is designed for one-hour increments of time but can be adjusted as needed. It can be repeated multiple times per day depending on how much time you intend to practice, however doing physical warm-ups at the beginning of each session and stopping every twenty minutes to stretch and take a 5-minute break is essential.  Practicing in one-hour increments or less multiple times per day is ideal, but if you must practice for multiple hours at once, be sure to take a 15-minute break every hour.  It is helpful to write a list of your goals for each session at the top of the template, such as “slow, technical work from measures 56-62 in Piece A”, “clarity of articulation and supportive air speed from measures 78-94 in Piece B”, etc.  Efficient Practice Template Download

It is also important to incorporate variety within this daily schedule.  Doing the exact same warm-up routine and practicing the same passages can lead to burnout, limit productivity and take away the joy and freedom that is possible during your practice sessions.  If you find yourself in a rut, substitute one 10-minute section of detailed repertoire practice per day and devote it to free improvisation or learning repertoire that you love.  Having a strict daily regimen for practicing works well for some people, but for most it can lead to exhaustion and tension, because our bodies and minds tend to naturally rebel after a certain period of time of being told exactly what to do.

If you are feeling burnt out, it is time to re-examine your daily practice routine.  Ask yourself, when was the last time I spent time outside?  When was the last time I hung out with a friend for fun?  Do I notice myself making progress or do I feel like I am in a rut?  Does practicing feel like a forced act and do I feel guilty for enjoying life outside of the practice room?  We must develop a healthy balance between our work lives and our personal lives.  As musicians, it is easy to overlook the opportunity to have a personal life because our work frequently exceeds the typical 9-5 workday hours, and our justification is that the more we practice the more we will improve.  Working yourself to the point of exhaustion and not giving your body back what it needs will actually have the opposite effect and often cause you to perform worse than you desire. 

Taking care of yourself is a non-negotiable element of becoming a professional musician.  Being a student in the 21st century comes with its unique set of challenges, and the pressures of fast-paced schedules and having everything at your fingertips through social media and smartphones can add stressors to an already competitive industry.  The rate of performance-related injuries is quickly rising, but there are also more resources dedicated to promoting awareness of performing arts health and treating performance-related injuries.  Treat your mental and physical health as your priority and watch your musical success and productivity flourish as a result.

Bibliography:

“Identifying the Injury:” (Stanek, Komes & Murdock, 2017):  https://www.ncbi.nlm.nih.gov/pubmed/28282475

(Mitchell, 2017): http://www.working-well.org/articles/pdf/Musicians.pdf

"Managing Your Time:" (Klickstein): https://www.musiciansway.com/blog/2011/06/efficient-practice/

Alexander Technique: https://www.alexandertechnique.com/at/

Bursitis: https://my.clevelandclinic.org/health/diseases/10918-bursitis

Tendonitis: https://my.clevelandclinic.org/health/diseases/10919-tendinitis

Carpal Tunnel Syndrome:

https://my.clevelandclinic.org/health/diseases/4005-carpal-tunnel-syndrome

RSI:

https://my.clevelandclinic.org/health/diseases/17424-repetitive-stress-injury

TMJ:

https://my.clevelandclinic.org/health/diseases/15066-temporomandibular-disorders-tmd-overview

Vocal Cord Lesions:

https://my.clevelandclinic.org/health/diseases/15424-vocal-cord-lesions-nodules-polyps-and-cysts

Thoracic Outlet Syndrome:

https://my.clevelandclinic.org/health/diseases/17553-thoracic-outlet-syndrome-tos

Biography

Francesca Leo is a cutting edge New York City-based flutist and entrepreneur.  A fierce advocate of performing arts health, she currently serves as a board member of the National Flute Association Performance Health Care Committee and the Southeast Michigan Flute Association, and is the founder of the award-winning website http://www.playingwithoutpain.com.  Francesca is currently pursuing a master's degree in Classical Flute Performance on the Joseph F. McCrindle Scholarship at the Manhattan School of Music.