The Flutist’s 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 keep shoulder blades down)

The big thing to remember here is to that before and DURING the movement, keep your shoulder blades pulled back and down.  This will prevent you from going into full shoulder extension and increase shoulder stability.

Huh?

That means that when your arms are as far away from you as they can be, if your shoulder blades are properly retracted and depressed you will still be able to let your arms go farther away.  So, when you are reaching up for the bar, don’t let your shoulder blades float away – keep them back and down.  If you find you can still let them go a bit farther (like in the second picture), you know they are not properly retracted. Think of keeping the bottom of your shoulder blades squeezed together throughout 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.

Inverted Row

Coaching cues: keep body “straight”, keep shoulder blades back and down.

Coaching cues: keep shoulder blades back and down, keep neutral arch in back, do NOT round your back when reaching for weight or pulling forward

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 10-30, depending, 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

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.

Related articles

• Shoulder Pain Secret (fluteangel.wordpress.com)
• Shoulder Pain Part 1 (fluteangel.wordpress.com)
• Identifying Shoulder Pain Part 2 – What To Do About It (innovativeperformanceandpedagogy.wordpress.com)
• Identfying Shoulder Pain Part 2 – What to Do About It (fluteangel.wordpress.com)
• Identifying Shoulder Pain – Part I (innovativeperformanceandpedagogy.wordpress.com)
• De-Mystifying Support and the Diaphragm (innovativeperformanceandpedagogy.wordpress.com)
• Geoffrey Gilbert and the Use of the Body: Taking a Look at “The Gilbert Legacy” for Tips (innovativeperformanceandpedagogy.wordpress.com)
• 3 Exercises + 1 for Core Strength and Stability (innovativeperformanceandpedagogy.wordpress.com)
• What Interests You? (fluteangel.wordpress.com)

De-Mystifying Support and the Diaphragm

As a wind instrumentalist, and especially as a flutist, I hear this question a lot:

“What is support?” which is usually followed by this statement

“Make sure you breathe/support from the diaphragm“.

I hate to tell you, but that is absolutely impossible. The intentions, when this statement is said, are good, but let’s talk about the diaphragm for a minute.

First, what IS the diaphragm? Well, looks like it’s time for a little body mapping. 🙂

The diaphragm is a thin, dome-shaped muscle that attaches to the bottom of the breast bone, the front of the chest wall, the inside of the cartilage of the bottom 6 ribs, the end of the 12th rib, ligaments and also to the lumbar (lower) spine. It’s HUGE, as you can see – does it look how you thought it would look. Think about yourself, touch the parts where it connects, this will correct your own body map.

Why is it impossible to “breathe from the diaphragm”? The diaphragm is an involuntary muscle – meaning that it cannot (in most circumstances) be consciously controlled. You breathe in and out and it is regulated by your subconscious. What is meant when well-meaning teachers tell you to “breathe FROM the diaphragm” is really that you should not breathe shallowly but rather breathe low. My favorite image being “breathe through the bottom of the chair”. In any case, I’ll show you more about what support really means and how to breathe well.

Why should I care how I breathe?

Mark, over at Mark’s Daily Apple wrote a great article about breathing properly – and as far as I know, he’s not a musician!

Patrick Ward has written a great series of articles on breathing and the role of the diaphragm in lifting. He’s a Certified Strength and Conditioning Specialist AND a Massage Therapist. I highly recommend checking out his articles if you want more information:

Breathing 101

We are all basically saying the same thing – there is a “correct” and “incorrect” way to breathe. Whether you are breathing for lifting, for playing an instrument or just in general, correct breathing involves the abdomen extending and the shoulders remaining mostly stable.

Try this: put one hand on your shoulders or upper chest and the other on your abdomen. Take in a deep breath. What moves? If you are breathing correctly, your abdomen should move and your shoulders should not.

Keep your hands there and do it again, this time, concentrating on breathing low and letting your abdomen move. Notice I said LETTING your abdomen move, not moving your abdomen. There is a big difference. Once you’ve done this, and if you were breathing shallowly before (aka: your shoulders were moving before) you should feel a little weird.

Let’s move the experiment further. Put one hand on your abdomen and the other on your low back. Take in a deep breath and you should feel expansion all the way around, including your low back!

Here’s Patrick Ward demonstrating the above:

What is happening when I breathe?

When you breathe, the diaphragm moves down, pulling the lungs down so they can suck in air. When this happens, your guts have to go somewhere and so, the act of inhaling actually causes your internal organs to shift downward, creating internal tension. When you exhale, the diaphragm moves upward, causing the air to be pushed out of the lungs and the internal organs return to their original position. What you are feeling in your low back is the same as what you are feeling in the front: your internal organs being shifted all around!

How do I translate this to “support”….and what does that mean, anyway?

I’m glad you asked. 🙂

If you can’t “breathe from the diaphragm”, what CAN you do and how is support really achieved?

Amazingly enough, it took me till I was 25 and in graduate school before this was actually explained to me and I really understood it. It took some change and getting used to it, but once I was able to implement proper support, my sound improved dramatically, and so did the tension levels in my body.

To understand support, let’s go back to the original exercise involving breathing with your hands placed on your abdomen. This time I want you to place your hand on your lower abdomen, the spot below your belly button, and inhale. You SHOULD feel this area expand outward. In fact, if you wear low-rise pants, this is probably where your waistband falls. Feel the tension that is created there. It is not a huge thing, and you probably never noticed it till now.

This is the key to support (at least for flutists): while keeping your hand on your lower abdomen, exhale and keep the tension under your hand. Only when you are almost completely out of air should you let the tension go and your abdomen retract. Try it again: hold the tension as you breathe out, meaning, hold your abdomen against your hand or the waistband of your pants.

This is very important: DO NOT PUSH against your hand, merely hold the tension that is naturally there. If you push you run the danger of incurring a hernia! This should not be harsh or painful, but there will be a good chance of a few things 1) you feeling strange and 2) your stomach making gurgling noises. 🙂

To apply this to playing your flute:

Play a G, this allows your right hand to remain on your lower abdomen. Be very gentle with yourself and notice how you feel all over: throat, tongue, stomach, etc. As you play your G, make a conscious effort to hold the tension out under your hand.

Pay attention to your sound – do you sound more open? Louder? Fuller? Stronger?

Pay attention to your throat – if you were used to playing with an involved throat, it may be at a loss for what to do. Let it relax and get out of the way. You do not need your throat to play the flute. If what you are doing currently causes your throat to hurt and feel tight when you play, this will solve that problem. What you are doing is shifting the support from your throat to your abdomen, where it belongs. This creates that elusive and confusing “air column” that we have heard so much about. 🙂

Pay attention to your tongue – if you let your throat go, very likely your tongue will want to compensate and try to support. Keep your tongue resting in the bottom of your jaw. This creates an open cavity in your mouth, through your throat, all the way down. You very likely will find the back of your tongue rising to try to “support” the air. When the air is supported from down low, where it should be, the tongue does not need to help. When the air is unencumbered by a tight throat or tongue, the sound will soar!

Supporting from your lower abdomen is very strange and takes some getting used to. Don’t be surprised if you find your body resisting and other body parts trying to take over the job. Most likely your throat will try it, when you let your throat remain uninvolved, your tongue will want to do it. Be prepared for this and aware of it.

Helpful Exercises for Musicians AND Fitness Enthusiasts

If you find yourself shallow breathing and actually having a difficult time with breathing correctly, you can implement these exercises to help you improve your breathing. This will make proper support much easier.

These exercises are also good for all you lifters! Proper breathing technique is essential to help you maintain form and lift more weight.

I should also mention my post awhile back about exercises for the core. There are a LOT but these are just a few that will help you with a strong core. When your core (read: muscles of the entire trunk) are strong and working together, learning how to “support” will come much easier to you. Article: 3 Core Exericses + 1 for Core Strength and Stability

Related Articles

• How to Breathe Correctly (marksdailyapple.com)
• Breathe With Me (plentyonyourplate.com)
• What is the difference between the placenta and the diaphragm (wiki.answers.com)
• De-Mystifying Support and the Diaphragm (fluteangel.wordpress.com)
• 3 Exercises + 1 for Core Strength and Stability (fluteangel.wordpress.com)