Case Studies


Repetitive Strain Case Study #1

When I developed deep pains in my forearms in March of 1994 following three intense weeks of unaccustomed 8-hour days at the computer, I knew it was serious trouble. I even knew it was called Repetitive Strain Injury. But I was pretty sure some good ergonomic computing equipment would fix it, that and the splints and ibuprofen my physician's assistant prescribed for me.

What I didn't know yet was that my approach to playing guitar and other instruments may have been a significant contributing cause of my bilateral flexor tendinitis. Despite splints, drugs and ergonomic computer equipment, real recovery was elusive, not the least because I hardly slowed down my frenetic pace on computer OR on my instruments. But after I rehearsed and performed a Christmas oratorio on violin, I found myself in frightening pain and having increasing trouble with dexterity. I asked for and got a referral to a physical therapist, who after a time of evaluation laid it out for me: I was in for a long, difficult recovery, and I needed to reduce or modify all activities that aggravated my tendinitis.

No phrase is more common to musicians experiencing physical problems than "I can't stop practicing" . . . " because we have a recital", or "we need to keep a paying gig", or "our music is in our blood and we can't bear to leave it be". But reality is reality: my guitar and violin went in their cases and stayed there untouched for months while the damage slowly repaired.

There were a great many things that contributed to the return to functionality and relative freedom from pain I enjoy today: physical reeducation for my body, ice water baths for my arms, gentle stretching, microcurrent therapy, meditation to reduce stress, and more. But I'd like to address some specific points about the steel string acoustic guitar, which is my main instrument and which I believe caused me the most trouble.

Maybe one of the most important things to learn is you don't have to fret so darn hard. Some instructors suggest fretting notes with ever-decreasing pressure, until finally the string actually buzzes because it's not fretted enough. Just a little bit more than that is all it takes to play cleanly, even during vigorous pieces. "Digging in" may feel like you are wrenching more tone from the string, but it just ain't so. (When you strike the strings harder you may have to increase your fretting pressure a bit.) The same rationale applies to the picking hand, as well: excess tension in finger- or flat-picking does not add to your tone, and besides causing injurious strain it impedes your speed and dexterity. If you are fond of using a flat pick, you may find using a thumb pick may reduce the amount of force needed to hold the pick. Using more of your whole arm to pick instead of doing it all with your wrist is frequently recommended as well.

And the moment pressure or movement is no longer required from any finger, relax it. Give those muscles and tendons a momentary chance to recharge and flush waste products away.

Electric guitarists are notorious for preferring postures and positions that look cool over those which are least stressful and most musically effective, but even a classic guitarist sitting in the refined one-foot-elevated position may be creating physical problems through hunched shoulders, cocked wrists, and the tilted hips that come with the use of the footstool. I can't begin to address all the aspects of correct posture, but I will pass along Aaron Shearer's sound advice that to the greatest extent possible, all joints - shoulders, elbows, knuckles, fingers, wrists - should operate in the middle of their range of movement. Shearer explains correct positioning in depth in his excellent book LEARNING THE CLASSIC GUITAR, Part I which while intended for the classic guitarist provides principals that can be applied to steel string and solid-body guitars.

My own practice has changed in that I try to play standing up with a strap whenever possible, which permits me to move and avoid any fixed, tense position. Instead of the neck extending out parallel to the floor, I minimize my left-hand contortions by angling the neck up at about 45 degrees from the horizontal. One injurious habit I'm finding hard to break is holding my left shoulder up when I play. Shoulders should be allowed to drop, and raising the arm done through the rotation of the shoulder joint, without any "help" from a raised shoulder.

A controversial point of positioning is placing the left-hand thumb behind the neck to optimize reach and fretting strength: this is generally accepted as "correct" classic technique. But it can be very hard on the thumb, and letting the neck fall into the web between the thumb and fingers instead should at least be considered as an optional change of pace to rest the thumb. Too, overuse of full barre chords maximizes the amount of left hand strain; my playing and writing style has changed to emphasize partial chords and alternatives to full 6-string barres.

Changes to the instrument may help avoid injury. Lighter strings are an obvious method to reduce strain on the hands. This will likely alter your tone and may require a change in your playing style or an adjustment in your instrument setup. Along the same lines, tuning down a half or whole step not only reduces string tension further but opens up new tonal possibilities.

Using a capo restores the concert pitch of a guitar detuned in this way, but in addition it shortens the effective scale of the guitar to minimize left hand stretches. My "standard" setup has my guitar detuned one whole step and then capoed two frets up.

One option to ease playing problems is to get an instrument that is shorter, narrower, and/or shallower than the popular dreadnaught-style acoustics. Options include small bodied "parlor" guitars, very shallow-bodied acoustics/electrics, the round-backed Ovations, and
at least one "ergonomic" acoustic model where the body is shallower on one side than the other, so the right arm and hand do not have to reach around so much body. Though it may sound unthinkable to the acoustic purist, solid-body electric guitars offer advantages in shape and easy playing action, and with sophisticated electronic processing can provide usable "acoustic" tone. Chet Atkins and Joni Mitchell are two acoustic guitar masters who are using solid-body guitars in concert venues.

While these and other changes, and the healing of time, have given me back the ability to practice guitar and write new material, endurance remains a problem for me. After a half-hour trying out guitars in a music store recently, I found my fingers slipping, missing notes, and simply refusing to obey the commands of my brain. I'm hoping that gentle exercise over the coming months rebuilds endurance.

More resources on this subject can be found on-line on my Web site
Musicians and Injuries


Aaron Shearer Mel Bay Publications, Inc.
#4 Industrial Drive, Pacific, MO 63069-0066
Toll Free 1-800-325-9518
FAX 314/257-5062
Copyright 1998 Paul Marxhausen. All Rights Reserved.


Case Study 2: Postural Considerations in Flute Playing

Posture plays an important part in playing all instruments. Careful attention to this critical factor can alleviate many musculoskeletal complaints, enhance chest and lung volume, and ease up freedom of movement. In this article, we will examine a flutist’s posture and see how it relates to musculoskeletal stresses and lung capacity.

Three photos were taken of our subject, Jason Eckl, a music student at Cal. State Hayward. Shown here are some the most common postures witnessed in flute players, but it also relates to any instrument involving a seated posture. Violin, cello, woodwinds, brass and piano instrumentalists all can benefit by these suggestions.


In Figure one, the "slouched posture" there is compression of the anterior rib cage due to the increased curvature of the upper spine. This decreases total lung capacity, thus the lungs are taking in approximately 60% to 70% of their normal volume. Of course, this has a tremendous affect on the player’s capacity to maintain a continuous unwavering tone. The player also has an increased tendency towards developing spinal problems due to the tremendous stress to the upper back (thoracic spine). Notice where the arrow is pointing. The part of the spine has a increased curvature. Subluxations (misalignments) of the spine in this region not only can give localized back pain, but also pain in the front of the chest, and internal complaints such as heart, lung, and stomach irritations due to nerve compression. The lower back is also affected in this posture. Notice the arrow pointing at the low back. The slouched position forces the lumbar spine (low back) into flexion. This irritates the spinal ligaments and can compress nerves as well.

The slouched posture has another drawback. Once you anchor your body against the chairback, you loose freedom of movement of the torso. This forces all movement to be translated to the upper extremities, leading them prone to repetitive strain injuries such as tendonitis. Freedom of movement is imperative for musical expression. It would be quite difficult for a pianist to play expressively with his back resting against a seat. The same goes for any seated instrument. Cello players, for example, must use upper body movement to translate the bow across the strings. A slouched posture will force all bow movement to the shoulders, arms, and wrists, thus leading to strain in these structures. Just as a baseball pitcher uses his entire body to propel the baseball forward, so does a musician use her entire body to translate movement into her instrument to produce beautiful musical tones.


In figure two, Jason takes the preferred posture with ears directly above the shoulder and hips. This posture maximizes lung volume, allows for freedom of movement of the torso, and provides normal curvature to the lumbar spine. Jason simply tilts his hips slightly forward (about 5 degrees) to obtain maximum spinal relaxation. In fact, in this posture he has noticed a reduction of upper back soreness that has plagued him for many years.


Some musicians will achieve this posture with the help of foam seat wedges that have a forward decline. (See figure 3). This places the pelvis into a slight forward flexion, naturalizing the lumbar, thoracic, and cervical spinal curves.



Figure 4 shows the "forward lean" posture. How many of you do this to read sheet music on an improperly placed music stand? Notice how the neck arches forward. The average head weighs about 12 pounds. In this posture the neck extensor muscles must continuously contract to keep the head from falling forward. This leads to neck fatigue and the propensity towards spinal misalignments. Again, Jason is compressing his upper thoracic spine and rib cage. This reduces lung capacity, compresses spinal nerves and irritates the spinal ligaments.

An easy way to determine if you are sitting incorrectly is to have someone take photographs of you from the side while you are playing your instrument. This gives you a quick self-examination of your posture. You could also sit beside a mirror while playing to evaluate your posture. Either way, check your posture now to prevent injures from developing later.