Understanding Upper Strings

A couple of weeks ago I attended the most recent BAPAM (British Association of Performing Arts Medicine) conference in London for clinicians, primarily looking at issues and problems faced in upper strings players. The event was full of healthcare clinicians all with a special interest in the performing arts, so as well as a good educational day it’s great for networking as well.

So I thought I would do a summary of the interesting points and issues covered throughout the day.

First of all we had Dr Alan Watson from Cardiff University going over the the anatomy of the upper limb and some of the general issues and problems that can occur. As a more recent graduate I must say it was generally more of a refresher, however there were two key points coming out of it.

  1. Sitting posture while playing

A fairly obvious point and one that is pretty much embedded in every musicians injury prevention guides, but I’ll focus on the shoulder here and the point is quite simple.

Your shoulder has the most amount of movement when you are sitting comfortably upright.

Now this doesn’t mean that whenever you are playing you need to be sitting bolt upright and tensing the entire time trying to keep a straight back like you’re a soldier on parade, but you do need to be conscious that you are not sitting too far forwards or backwards while playing for a prolonged period (e.g. more than five minutes).

If you sit too far forward then you actually reduce the amount of movement the shoulder has to move the arm upwards (flexion). It works the opposite way as well as if you sit too far backwards, you reduce the amount of movement the shoulder has to move the arm down and backwards (extension). Have a go now and see for yourself, and then compare when sitting in a normal neutral position afterwards.

Sitting leaning too far forwards.
Sitting leaning too far backwards.
A good neutral sitting position.

The anatomy behind it is that the shoulder blade actually connects with the spine, so when your body leans forwards or backwards, the shoulder blade moves the same way as well. So when you lean too far forward the shoulder blade is leaning forwards as well, and as you raise your arm upwards the top of your humerus ( upper arm bone) bumps into the top of your shoulder blade called the acromion (lump on the top of your shoulder) causing it to stop going any higher. If you lean too far backwards then the top of the humerus bumps into the bottom of the cup of the shoulder blade where it meets with the humerus called the glenoid cavity, which in turn stops it going any further backwards.

The importance of this restricted movement is that it can cause an alteration in the way an upper string player has to play their instrument, meaning they have to contort their bodies and use muscles and joints in certain ways where they are not normally suited to work. This can in turn lead to variety of issues and problems developing, which I won’t delve into here as otherwise we’ll be here all day.

2. Linburg-Comstock Syndrome

Not really a point just more something I hadn’t heard of before and found  quite interesting.

Linburg-Comstock syndrome is an anatomical abnormality in the hand, which Alan states is found in roughly 20% of all people, although the majority wouldn’t notice that they have it unless they went looking for it.

Linburg-Comstock syndrome is where the tendon that pulls your thumb towards your palm  (Flexor Pallucis Longus) and the tendon that bends your second finger (Flexor Digitorum Longus) are joined together by a small tendon usually at the wrist point.

What does this mean?

Well although it is called a “syndrome” it doesn’t usually cause any pain or altered sensations at all, that’s why most people don’t notice it.

What it does it mean though is that whenever either of the tendons contract it causes the other to contract as well. So if you had Linburg-Comstock syndrome and tried to bend your thumb in towards your palm it would result in your second finger bending as well, and vice versa. In those that don’t have Linburg-Comstock syndrome they would be able to bend their thumb or 2nd finger without the other one bending. Have a go now to see if you have it (or not).

A minor presentation of Linburg-Comstock syndrome.

Like I said it generally doesn’t actually lead to any pain or central issues at all, although it can mean fine finger tasks (such as playing a musical instrument) are more difficult for those with the syndrome.

On a completely unrelated note those with a spare £50 can buy Alan’s book titled “The Biology of Musical Performance and Performance-Related Injury” which has been given some pretty decent reviews (Alan if you’re reading this and want to send me a free copy for the plug then I’ll be more than happy to accept).

Next up we had Dr David Fielding covering some of the issues that upper string players specifically develop. Again posture and performance set up as described above were crucial in determining if an artist was more at risk of developing an injury.

The way the artist plays the upper strings appeared to be the main contributor towards musculoskeletal issues, although as I am no expert on the upper strings I won’t delve into how to play the violin correctly. But I will say that it often varies from person to person, and a position that is comfortable and suitable for one artist may not be for another.

This brought up a thought that musical students will usually learn an instrument in a similar way to how their teacher plays it. Now usually this is fine, but if you have a teacher and a student with very different physiques then the teachers position and way of playing may not be suitable for the student, and hence may actually put the student at risk of developing problems if they learn to play that way. Obviously this was just a theory, and I would hope that most musical teachers would teach their students how to perform and play in a way suitable for them, but feel free to add any thoughts or ideas in the comments below.

It also raised the issue of how do we encourage musical students to maintain good posture and form while playing themselves? Well one idea could be to have bonus points offered during musical instrument gradings for good posture and form during performance of pieces. This encouragement may be enough for musical students to be feel confident and natural playing in a suitable, safe posture and form and hopefully reduce their risk of developing performance related issues, but for now it is just an idea.

After lunch we had Drusilla Redman (Physiotherapist) take us through a warm up session designed for musicians prior to going out and performing, which was probably more exercise than most of those in the room had done in a while. But I must say I was pleasantly surprised how active and dynamic it was, without any static stretching at all.

I tried to upload a copy of the exercise programme but alas technology is failing me and it’s coming out too blurry to read. Essentially it should take 15-20mins in total where you are moving all joints of the body, no matter if it’s involved in the performance or not, and then add in a bit of light cardio as well.

After this we had Dr Alison Loram an Alexander Teacher and Violinist explaining how the Alexander Technique can help upper string players overcome performance related issues, and from her research showed how those with performance related issues due to postural abnormalities are able to correct this with just verbal feedback (you have no excuse!).

During the discussion a fellow physio piped up and stated that she didn’t feel that there was much difference between the Alexander Technique and postural adjustments often carried out by physios. At first I was in agreement with this statement but afterwards I had the pleasure of being driven home by Sarah Upjohn, a Physio and Alexander Teacher who explained the differences which has been quite nicely summarised here:


Finally we had Dr Ulla Benz discussing the demands that are placed on performing upper strings players.

She gave some quite good ideas which I will summarise here:

  • Never practice in a cold environment as it will cause your body to generally become tighter, giving you less amount of movement to play, and hence increasing the risk of injuries developing.
  • Ensure you do a proper warm up and cool down after practicing and performing.
  • If you will be practicing for several hours, then practice for 30 minutes at a time, then have a 5-10 minute break repeatedly.
  • You should not be excessively bending your neck down or tilting it backwards while playing for prolonged periods.
  • Your fretting hand and wrist should always be straight while playing, not bent.
  • The quality of the performing environment (e.g. stage, chairs, lighting, music stands etc) should ideally be assessed by the performer prior to playing so that it is in the most ideal set up for them.

Have mobility while playing and never stay in a static posture.

I found this to be the most essential point, and Ulla actually showed a great way to achieve this while still being able to perform a piece correctly. As she played a classical piece on her violin, she simultaneously rocked her fretting elbow up and down and rolled her right shoulder backwards and forwards. Imagine rubbing your stomach and patting your head at the same time, then throwing a violin on top.

Yes it is technically challenging and requires skill and practice, but the idea is not for showing off. The point of it is that it allows you to maintain movement at your joints during prolonged playing periods, preventing the soft tissue around them getting tight, and hence preventing performance related injuries in the long term.

In fact I thought it was such a good idea that I tried it myself with my guitar, but being an egotistical man I wanted to push it further and try to move all four limbs while playing at the same. The results are below you can judge for yourself how good (or bad) it was.

Otherwise it was a great day and I look forward to attending the next event for clinicians in Manchester in May 2016, and would recommend any healthcare professionals with an interest in the performing arts do the same.

Have a nice day.



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