Musicians as athletes
I affirm this with the conviction of someone who knows these two universes well: musicians are high-performance athletes, but they do not treat themselves as such. Professional musical performance and high-performance sports require very similar levels of commitment, as well as physical and mental demands. The time, commitment and consistency required to achieve a high level of performance playing an instrument or performing a specific sport skill have much more in common than one might initially think. Some differences will lie in the fact that, in general, neuromuscular recruitment associated with playing an instrument has a greater focus on fine motor skills (i.e. short movements of greater precision and performed mainly with the limbs extremities) and less at the level of gross motor skills (i.e. larger movements involving larger muscle groups) that we normally associate with sports movements. However, it should be clarified that both large muscle groups play an important role, particularly at a postural level, in instrumental performance, and the smaller muscles associated with fine motor skills also play a fundamental role in most sports movements.
For example, if we establish a parallel between playing the violin and performing a given sport specific skill in tennis, we find that, although at different levels, a balance of fine and gross motor control is necessary for better performance in both activities. When we play the violin, we want to maintain a high and controlled posture so that holding the violin with the non-dominant arm and handling the bow with the dominant arm allows the fine work of the hands and fingers to occur as efficiently as possible. Now, if the musculature involved in the stabilization of the trunk and in the elevation of the arms is weak, fatigue sets in more quickly resulting in postural loss, in an execution carried out with greater muscle tension and consequently in a worse performance. In the case of the serve in tennis, due to the high demand for motor coordination and strength involving all the large muscle groups of the lower and upper body, there is also a need for high levels of fine motor skills coordination regarding wrist, hand and finger movements, in order to implement a given spin effect and the desired direction to the ball.
In fact, both musical and sports performance involve neuromuscular recruitment to produce movement and work that requires precision, speed, endurance and strength. In addition, and particularly at a professional level, playing an instrument and playing a sport are activities that require long hours of repetitive movements that, combined with poor physical conditioning, can lead to a variety of clinical conditions. It is unthinkable that a highly competitive athlete does not follow a training program targeting the development of his/her physical qualities which should be complementary to the practice of his/her sport. It is easy to recognize that a good physical fitness level will ensure greater resilience and longevity in sports. The same applies to musical performance. Musicians are high-performance athletes and should prepare themselves as such! Living and playing with pain is not inevitable, it is an option.
The prevalence of pain and injury in musicians
As the years go by and the hours playing their instrument accumulate, it is almost inevitable that professional musicians develop musculoskeletal and/or neuromuscular problems of varying severity at some point in their career. More so if they do nothing about their physical preparation. Review studies on the prevalence of injuries in professional musicians point out that 76% of musicians suffer or have suffered from physical problems that prevent them from performing at their usual level and 84% had injuries that interfered negatively with their musical practice1. Some musicians will develop tendinopathies and low back pain of varying intensity, which they will be able to manage with chronic intake of anti-inflammatory medications or simply by playing less frequently and/or just by enduring pain and discomfort. Others will develop more serious overuse injury syndromes that will become chronic and compromise not only quality of musical performance, but also quality of life, forcing them to periods of musical inactivity. Additionally, others will suffer from even more serious forms of injury that may result in abandoning their career as an instrumentalist musician.
In general, the most frequent injuries affecting musicians manifest themselves through pain and/or dysfunction, especially on the joints, tendons, ligaments and nerves of the upper limb, head, neck and spine. For example, in orchestral instrumentalists, injuries of musculoskeletal and/or neuromuscular origin are more common and affect about 64% musicians, of which 20% consist of peripheral nervous problems and about 8% of cases of focal dystonia2. It makes sense, considering that these are the most stressed areas of the body during instrumental practice. An exception would be the cases of focal dystonia, which, although it may be accompanied by pain and musculoskeletal injury, the root cause of the dysfunction observed at the peripheral level is actually central, that is, the dysfunctional neuronal circuits are at the upper levels of the central nervous system such as the cerebral cortex. Thus, the most frequent injuries in instrumentalist musicians can be summarized as follows3:
- Musculoskeletal injuries – epicondylitis, tendinopathies (tendinosis, tendinitis, tenosynovitis), bursitis, arthritis, arthrosis, osteoarthritis, contractures, injuries to the temporomandibular joint;
- Nerve trapping and inflammation – carpal tunnel syndrome, thoracic outlet syndrome, radial tunnel syndrome, ulnar nerve compression syndrome, ulnar tunnel syndrome, cervical and lumbar radiculopathies;
- Focal dystonia;
- Hearing loss.
The onset of injuries in musicians is due to an array of factors that naturally interact. Several authors have identified the following factors facilitating and/or causing the development of injuries in musicians1:
- Physiological and biological factors such as gender and age. Women seem to be more likely to develop peripheral musculoskeletal and nerve injuries compared to men, and individuals who engage in high volume instrumental practice at an early age, at 4-5 years of age, are also more likely to develop injuries later in life4,5. In the case of focal dystonia, there is a clear higher prevalence in males (over 90%) and in women with menstrual disorders, which suggests that hormonal factors may be predisposing to the development of this disorder6.
- Type of instrument. The characteristics of the instrument (size, shape and weight) and the time of practice imply different levels of physical demand, in which fatigue onset and an execution based on too much physical effort can lead to the development of injuries7. For example, the position needed to play the clarinet implies that the entire weight of the instrument is supported on the right thumb, and at the same time it requires a large amount of short and fast movements of the fingers of both hands8. Another example particularly special to me is the double bass. A bulky instrument with an air column of considerable inertia, which requires not only considerable grip strength to press on the strings, but also considerable whole body physical effort (which, can of course, be optimized with efficient technique) to move this column of air and make the instrument vibrate and produce sound. Anyone who has tried playing the double bass for a few minutes realizes the physical demands that playing this instrument encompasses.
- Instrumental technique. A poor instrumental technique, with non-optimized positions, based on physical effort rather than on movement efficiency, associated with long hours of practice without rest, will naturally predispose the player to pain and injury, especially in the wrists, hands, neck and shoulders9 .
- Specific technical demands. The technical demands of a particular musical piece that often requires high-speed and high-intensity execution, with fatiguing repetition of movements or maintenance of extreme hand positions for a long period of time. All of this creates high levels of mechanical stress and may cause injury10,11.
- Body asymmetry. In the same way that an athlete of a one-side dominant sport will try to compensate for these asymmetries by working out both sides of the body, a musician is in a similar situation, because playing an instrument implies asymmetrical work in very unnatural positions for long periods of time, which will favor the occurrence of various muscular imbalances12.
- Poor physical fitness. Good levels of strength and general physical conditioning are essential to maintain a good position to play an instrument for long periods of time. Most of these positions are very unnatural. Being in good physical fitness will allow to resist the onset of fatigue, recover more quickly between rehearsals or practice sessions, and in fact, it will allow to tolerate more hours of practice avoiding technique and performance deterioration7. Muscle imbalances and weakness resulting from long hours of sitting in certain positions and high volume repetition of short movements must be prevented through exercise programs aiming to strengthen the body globally, and at the same time to compensate for muscle imbalances induced by instrumental practice13.
- Other lifestyle factors. We know that lifestyle factors such as smoking or smoke exposure, alcohol consumption, sleep deprivation, malnutrition, poor hydration and obesity have very damaging effects at a systemic level on our body. Regarding neuromuscular injuries, we know that all these forms of toxicity weaken the body’s connective tissue (cartilage, tendons, ligaments, membranes), muscles and nerve conduction, predisposing to the development of localized inflammatory processes as well as chronic injuries. For example, did you know that obesity is highly predisposing to development of carpal tunnel syndrome?14 Or that smoking is strongly associated with development of injuries and dysfunctions in the shoulder?15
Preventing and resolving injuries in musicians
Any elite athlete empirically knows something that has long been supported by science. That the most effective way to prevent (and also treat) overuse or overload injuries due to high volume sports practice is to ensure good levels of physical fitness combined with good recovery habits, adequate rest and nutrition. Regarding physical fitness, it is unthinkable for an elite athlete, not to follow a regular physical training program. An athlete knows that this will have negative consequences both on sports performance and on the susceptibility for developing injuries. The athlete knows that the weaker his/her musculoskeletal system is, the greater the vulnerability to injury. The question is, and if we consider that professional musicians are required to engage on activities requiring high physical and mental performance for long hours of daily practice, shouldn’t musicians treat themselves as high-performance athletes? I am certain that they should.
In fact, a 2019 systematic review investigating the topic of physical training for professional orchestra musicians1 indicates that following a structured physical training program of varying durations (from a few weeks to several months) has generally resulted in significant improvements in musical performance and in reducing (and even eliminating) chronic pain1.
To keep playing at the highest level for a long time, musicians would greatly benefit if they treated themselves as high-performance athletes and ensure that they maintain good physical shape combined with good habits of recovery, rest and nutrition. And to be clear, when I talk about staying in good physical shape, I don’t mean playing sports. In fact, playing sports as a mean to improve one’s physical fitness is not ideal and can even be harmful. More activity with asymmetric characteristics would be added on top of another, also asymmetric, which is playing a musical instrument. In general, all sports are constituted by specialized movements, and for that reason, also asymmetrical. So, except for purely recreational reasons (which can also be positive at a mental and stress release level), the practice of a sport as a strategy to improve physical fitness is not ideal and should not be the first choice particularly by musicians (I discuss this very topic in this article: Why musicians should not play sports).
General physical fitness is improved through the process of training our physical qualities. This should entail an assessment of the initial status in order to identify specific limitations and outline a specific intervention strategy. One should always start at the base and progress from there, just like the process of learning to play a musical instrument. Here, attention to detail is key. A well-designed training program implies the management of training variables specific to the profile and objectives of the athlete or, in this case, the musician. A correct selection of exercises is crucial, as well as close monitoring of their implementation regarding form of execution, training load and progression over time. As I mentioned, it is not very different from the process of learning to play a musical instrument!
For a musician, playing the instrument is the top priority. It can be obsessive, I know. But playing better in the long run does not necessarily mean playing more hours, but rather investing in taking care of the ‘’machine’’ that is our body. I reiterate once more that playing with pain or discomfort is an option and not an inevitability. Take care of your body and treat it well, because you will need it in the long run!
Train well to play well!
- Gallego, C., Ros, C., Ruíz, L., Martín, J. (2019). The physical training for musicians. Systematic review. Sportis Sci J, 5 (3), 532-561.
- Lederman, R. J. (2003). Neuromuscular and musculoskeletal problems in instrumental musicians. Muscle & Nerve, 27(5), 549–561.
- Betancor Almeida, I. (2011). Hábitos de actividad física en músicos de orquestas sinfónicas profesionales: un análisis empírico de ámbito internaciona Tesis Doctoral. Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria.
- Fishbein, M., Middlestadt, S., Ottati, V., Straus, S., y Ellis, A. (1988). Medical problems among ICSOM musicians: Overview of a national survey. Medical Problems of Performing Artists, 3(1), 1–8.
- Viaño, J. J. (2004). Estudio de la relación entre la apariciación de lesiones musculoesqueléticas en músicos instrumentistas y hábitos de actividad física y vida diaria. En III Congreso De La Asociación Española de Ciencias Del Deporte. Valencia: Universidad de A Coruña.
- Rosset-Llobet, J., Candia, V., Fàbregas, S., Ray, W., & Pascual-Leone, A. (2007). Secondary motor disturbances in 101 patients with musician’s dystonia. Journal of neurology, neurosurgery, and psychiatry, 78(9), 949–953.
- Sardá, E. (2003). En forma: ejercicios para músicos. Barcelona: Paidos.
- Thrasher, M., y Chesky, K. (1998). Medical problems of clarinetists: Results from the U.N.T. musician health survey. The Clarinet, 25(4), 24–27.
- Wynn, C. B. (2004). Managing the physical demands of musical performance. En Williamon A. (Ed.), Musical excellence: Strategies and techniques to enhance performance (pp. 41–60). Londres: Oxford University Press.
- Bejjani, F. J., Kaye, G. M., y Benham, M. (1996). Musculoskeletal and neuromuscular conditions of instrumental musicians. Archives of Physical Medicine and Rehabilitation, 77(4), 406–413.
- Mark, T., Gary, R., y Miles, T. (2003). What every pianist needs to know about the body: a manual for players of keyboard instruments: piano, organ, digital keyboard, harpsichord, clavichord. GIA Publications. Martín.
- Ackermann, B., Adams, R., y Marshall, E. (2002). Strength of endurance training for undergraduate music majors at a university? Medical Problems of Performing Artists, 17(1), 33– 41.
- Frabretti, C., y Gomide, M. F. (2010). A saúde dos músicos: dor na prática profissional de músicos de orquestra no ABCD paulista. Revista Brasileira de Saúde Ocupacional, 35(121), 33– 40.
- Shiri R, Pourmemari MH, Falah-Hassani K, Viikari-Juntura E. The effect of excess body mass on the risk of carpal tunnel syndrome: a meta-analysis of 58 studies. Obes Rev. 2015;16(12):1094-1104.
- Bishop, Julie Y. et al. (2015). Smoking Predisposes to Rotator Cuff Pathology and Shoulder Dysfunction: A Systematic Review. Arthroscopy, Volume 31, Issue 8, 1598 – 1605.
This is an article on a topic that is very special to me. I’m going to talk about myself, about music, about musicians, about sports and about physical preparation.
I will explain how it is possible to play at the highest level for many, many years in a healthy way and without having to practice endless hours of scales with perfect technique. I will explain how it is possible to avoid tendinitis and other musculoskeletal injuries that typically affect musicians sooner or later, which result from long hours of practice of repetitive gestures in very “unnatural” positions. Yes, it is possible to avoid, mitigate or even eliminate pain in your back, shoulders, neck, elbows, wrists and fingers, which are so common among professional musicians.
Me and music …
Those who have known me for less than 10 years probably don’t know, but I have had a career as a professional musician for at least the previous 10 years. I’ve started playing bass guitar and at a certain point I switched to double bass. I’ve studied at several schools in Portugal (Lisbon Conservatory, Lisbon Superior School of Music and Hot Club of Portugal Jazz School where I would become a teacher) and graduated from the Conservatory of Amsterdam. I was in fact obsessed with playing double bass and particularly obsessed with playing it with perfect technique! I used to practice a reasonable number of hours a day and was able to subject myself to incredibly boring exercises for many hours in a row, just because I wanted to improve a certain aspect of my performance. I could practice about 10 hours a day. For the less familiar with music instruments, the double bass is a very physically demanding instrument, and 10 hours of repetitive gestures in unbalanced positions is very stressful on the body.
Due to long hours of musical practice, I developed a debilitating neuromuscular pathology (focal dystonia) that led me to a long rehabilitation process and to put my music career on hold. To know what focal dystonia is follow this LINK. In addition to focal dystonia, the list of complaints included:
- Frequent back pain, particularly in the lower back;
- Pain and stiffness in the neck, the sensation of having a wry neck that never went away;
- A thoracic kyphosis already up to a non-physiological degree;
- Protruded (forward) shoulders;
- Uneven hips. Because I spent many hours standing leaning mostly over my right leg and in slight lateral flexion, my pelvis was tilted to that side, just like my torso and shoulder. In fact, my right side was all “shortened”, as if I had one leg shorter than the other, which anatomically does not occur;
- Highly rigid and weak wrists, hands and fingers. For instance, I could not hold a push-up position on the floor with arms straight and shoulders over the hands, because my wrists would hurt and did not extend enough.
To aggravate all these imbalances caused by specific and repetitive gestures, my choices for physical activity (yes, because my past in sports impelled me not to be sedentary) relied on activities that were also specific and that also included repetitive gestures, that is, I would play sports! By definition, any sport and its related gestures are specific, cyclic, repetitive and asymmetric. There are sports “less bad” than others, but they are all asymmetrical. And no, swimming is not a complete sport, none is!
All this, and particularly the highly traumatizing and time-consuming process of neuromotor retuning that I underwent to treat dystonia, has prompted me to better understand processes related to the neuromuscular function, motor control, and musculoskeletal injuries. I decided to go back to the university and start a new career, and discovered other obsessions: anatomy, physiology, nutrition, strength training. And here I am today!
Musicians and the myths about “frailty” of their fingers and body …
I have to acknowledge, and my musician friends must forgive me, but musicians are usually very lazy to do any physical activity. We live to play our instruments and to be available for rehearsals. We make up excuses such as not having time and / or that our working tools (e.g. hands and fingers) are very “sensitive” and prone to injury if we engage in any vigorous physical activity. The fear of twisting a finger or cutting a lip (for wind instrumentalists) or even a foot (for drummers) is understandable! In fact, a finger injury for example may be enough to impede a musician from working for several weeks.
Who hasn’t witnessed or lived the situation where when playing soccer with friends those who are musicians try to avoid playing as the goal keeper with fear of injuring their fingers? Perfectly legitimate and understandable. And it’s precisely for this reason that if musicians want to get in better shape and ensure they can play music without injuries for many more years, doing sports is not the solution. They can do it for pleasure, and the energy expenditure that results from it can have positive metabolic effects. However, all asymmetries and musculoskeletal injuries that result from playing an instrument will not be corrected by playing a particular sport and will most likely will be worsened.
Musicians should do general physical preparation instead! Because a professional musician is a highly specialized high-level athlete. A high-level athlete practices his sport and in his training program is (or at least should be) included a very important component which is basic physical preparation. In his physical preparation program our athlete trains for strength, mobility and endurance, and other physical qualities in order to establish a general athletic base that will make him more resilient and protect him from injuries that his sport, which is repetitive and asymmetrical, makes him vulnerable to.
We don’t get fit FROM PLAYING sports, we should get fit TO PLAY sports. The repetition of specific sports gestures induces specific musculoskeletal adaptations. It is easy to understand that for an athlete, it does not make sense to try to compensate for a specific adaptation induced by a sport gesture with another one which might apparently look as an opposite one! For example, will it be smart for a right-handed tennis player to try compensating for the asymmetries resulting from playing with his right arm by engaging in the practice of table tennis with his left arm? Or, if our player exhibits pain in the right shoulder associated with lack of flexibility and strength, does it make sense to start practicing gymnastics just because apparently gymnasts have strong and flexible shoulders? No and no! This athlete should follow a program of general physical preparation to become stronger and more mobile, which can in fact compensate for the asymmetries induced by the sport that he practices.
What is the similarity between playing an instrument and practicing a sport? It’s the same…
Imagine compensating for the unbalanced position of playing double bass with playing another instrument in a seemingly opposite position?
Let’s explore that idea…
For example, playing double bass (a string instrument that can be played with a bow or fingers of the dominant upper limb) implies (usually) standing in a position characterized by unilateral rotation and flexion of the torso, accompanied by a forward leaning of the trunk, in a bipedal position with greater weight over the side of the torso’s lateral flexion, with elevation of both non-dominant arm and shoulder paired with depression of both dominant arm and shoulder, and rotation and slight lateral flexion of the head.
So, to compensate for or correct all these adaptations will it make any sense to go play the violin for example? Because apparently, it’s the opposite! You are (usually) sitting and not standing, the rotation and flexion of the head is in the opposite direction, where both dominant arm and shoulder are apparently more depressed, and the dominant arm raised …? Of course not…
By the same token, this musician will not be stronger, more flexible and more resilient to injuries due to his musical practice if he chooses to compensate for these adaptations with the practice of a sport. If you enjoy playing football or tennis with friends, you should do so, but it will not make you more resilient to injuries or attenuate the ones you may already have.
You must go to the basics: physical preparation.
Musicians should follow physical preparation program such as an athlete. Playing an instrument is highly specific and doing it regularly and long-term will require some specificity and in terms of exercises that can compensate for those unnatural positions that are held for such long periods of time. Yet, the basis of physical preparation will always be (for the athlete, musician, or any other) of a general nature. It is necessary to make the body stronger and more flexible, because only that way one can make it more resilient in order to endure the highly demanding physical requirements of playing a musical instrument for hours, days and years on end.
The pain and discomfort that you my fellow musician feel now, can improve with physical training! Smart training in a controlled environment. A kind of training that can make all the structures of our body stronger and less rigid. A kind of training that promotes a better alignment of the kinetic chain and that enables you to produce force in fundamental movement patterns such as pulling, pushing, lifting objects off the floor, squatting, crawling, walking and jumping.
And no, your body is not fragile! If it hurts, it’s because it’s somehow weak!
Believe me, I’ve been there, done that… ?