One of my favorite body parts to treat is the shoulder. Maybe because I relate to patients who have shoulder pain because of my own history, but maybe because it's like a puzzle with a ton of moving parts. The rockstar of the shoulder, of course, is the rotator cuff. But let's take a moment and talk about the often-times forgotten unsung hero - the Serratus Anterior.
With 17 muscles attaching to the scapula (shoulder blade), it's really easy to get lost in the complexity of it. Everything has to work "just-so". When we look at how the shoulder moves as we raise our arms either out in front or to the side, our shoulder blades move as well. This scapular motion allows us to reach above our heads without pinching or putting more compression on the rotator cuff tendon.
Source: Complete Anatomy
So without further ado.... let's introduce the star of the show - the Serratus Anterior.
This amazing, broad muscle attaches on the underside of the shoulder blade (sandwiched between the ribs and the scapula) and inserts into the first 8 (of 12) ribs. It gets its name from the Latin root "serrare" - meaning "to saw" based on its jagged appearanace on the ribcage. When it contracts, it works to rotate the shoulder blade upwards and wrap around your torso as seen in the video above. If the shoulder blade didn't go through this rotation, it would actually contribute to pinching or impingement of the rotator cuff tendons in the subacromial space.
The second function of the Serratus Anterior is that it keeps the shoulder blade close to the trunk. Without it, it would peel away, causing the shoulder blade to stick out or become more visibly prominent. Because your shoulder blade is not anchored by any ligaments except at the humerus and clavicle, it relies on the synchronization and stabilization through muscle co-contractions. People who have significant weakness in their serratus anterior will often exhibit more prominent, pronounced borders of their shoulder blades through movements of their shoulder girdle as seen in the video below. (hint: focus on the right side)
While there are many exercises that are useful to help strengthen this all-important muscle, here is a quick and simple one that I like to give violinists/violists to help build the endurance of their shoulders to help them be able to hold their instruments up for longer periods of time.
Remember - it is highly uncommon for a single muscle to work by itself without having other supporting players involved. The shoulder is no exception.
Make sure that you take time to put in the effort to create good balance throughout your body, but particularly in the shoulder. Having a good, solid foundation at the shoulder blade will help you be able to move more freely and improve the overall dexterity in your wrist and fingers.
That's it for this week! Til next time.... Stay happy and healthy!
Originally posted on www.corpsonore.com July 15, 2020
People often ask me why I decided to become a physical therapist. After all, most of my peers in my PT school cohort were either biology or kinesiology majors, and definitely NOT piano performance majors like me. My answer often begins with a stifled deep breath as I quickly decide whether to give the long or abridged version of my story. The short version goes something like: “I decided to take the scenic route and was a pianist and violinist before I got injured and decided to pursue physical therapy to help injured musicians.”
Truth be told, physical therapy failed me.
As an injured musician, I essentially tried every treatment under the sun - from months of acupuncture to several bouts of physical therapy treatments. My music teachers/professors could only offer me technique and postural corrections that seemed to make my pain worse. My PT gave me exercises that didn’t make any improvements to my symptoms. In the midst of my frustration, I realized that the error was not necessarily due to the people who were trying to help me, but that there was a huge void between the two disciplines that needed to be bridged.
As a PT, I’ve spent the last decade of my career working to develop treatment strategies for musicians of all types and genres. The realm of performing arts medicine has grown and evolved as more research has examined the things that affect us and make us tick. More musicians have a deeper understanding of anatomy, physiology and movement than I ever did as a young artist. Movement-based education such as Feldenkreis and Alexander Technique are more widely-recognized and accepted, musician health curriculum is now required in NASM accredited schools. Despite this, most of the research has observed significantly high rates of injuries among musicians compared to the average US workforce (54%)  without any significant decrease in injury rates since the first major prevalence study by Fishbein M, et al. in 19882 (76%) In fact, recent studies have actually found higher rates of injury (up to 93%) as of the most recent systematic review in 2016 .
The question is: Why?
The fact is that most instrumentalists spend many hours in awkward positions while playing their instrument without task-specific training to supplement their playing. Professional athletes spend hours training and strengthening for their specific sport. You would be hard pressed to find a pro golfer training the same way as a defensive lineman. Musicians should, and need to, look to train their bodies to withstand the physical demand required to play.
Only a few quality studies have looked at exercise training in musicians , much less with instrument-specific training. In both the music and performing arts medicine worlds, instrumentalists are typically divided into groups by families of instruments. Instead, we should really be looking more towards the postures used to play an instrument in order to help determine the best approaches towards “prehab” and “rehab”.
When we talk about injury prevention from a musculoskeletal perspective, it is never just about strength. In order to perform at our best, we must always be striving to find the goldilox balance between the appropriate strength, flexibility, and nerve mobility (not to mention psychology, nutrition, etc., but that’s for another discussion and other experts to also weigh in on).
Each instrument has its own physical demands associated with playing, and vary greatly from instruments to genres. In fact, it’s one of the biggest challenges as a PT who specializes in working with all types of musicians. For example, violinists, violists and flutists are presented with unique challenges compared to their other musician-counterparts because their playing positions force them to perform at more extreme ranges of their shoulders/wrists. In fact, they present with relatively high injury rates when compared to other instrumentalists , . For these artists, almost the full range of shoulder external rotation (90 degrees) in order to effectively hold the instrument (left shoulder for violinists and right shoulder for flutists).
If an artist doesn’t have the flexibility (either due to muscle tightness or their own anatomy), the body will cheat and find ways to still accomplish the task of playing. Additionally, the muscles that help support these joints should also be trained in these ranges. Just because you don’t have full range of motion, does not necessarily mean that you should not and cannot play. This is why playing is so individualized and not one-size-fits-all.
There has been a lot of impressive content on musician wellness emerging these days that I believe is beneficial for ALL musicians, regardless of the instruments played. Particularly when musicians grapple with the common debate whether strength training is beneficial or detrimental to their ability to play. Will strengthening cause me to lose my dexterity? Will putting weight on my hands while holding a plank or performing push ups hurt me? While the short answer is no, just know that there are many many ways to go about strengthening and are not limited to a core set of exercises.
If you are someone who either is suffering from an injury, or just looking to learn how to take care of yourself to prevent injuries, these are the 5 main suggestions I have regardless of where you are in your journey:
LEARN ABOUT YOUR BODY AND HOW IT WORKS
I do not believe that every musician should go through an entire anatomy course like I did, complete with cadaver dissections and mock surgeries. However, I strongly believe that ALL musicians should have a basic understanding of how muscles, nerves and joints work, and what muscles are instrumental to help them not only play their instruments, but also perform their daily tasks.
BECOME FAMILIAR WITH BASIC MEDICAL TERMINOLOGY
Nothing is scarier than the unknown, particularly injuries that you don’t know how to fix. The terms “carpal tunnel”, “tendonitis”, “overuse injury” are thrown around in our everyday vernacular, but oftentimes they are used incorrectly. If you understand what injuries are and what tissues are affected, you will be better equipped to take the first steps to try and modify your situation before going to see a medical professional. Don’t wait too long to ask for help. If you must see a medical professional like me, learn how to talk about your symptoms and their patterns (does your pain hurt after a long period of time? Certain positions? Repertoire change? etc.). We love to be detectives and help you overcome your obstacles, but if you aren’t able to give us a ton of information, it makes it more challenging to figure out.
YOU HAVE TO CRAWL BEFORE YOU CAN RUN
A common mistake I see instrumentalists and general patients alike make, is that they often rush into exercise programs without first assessing their baseline levels. You must have a strong foundation of strength and body control before you attempt to do more challenging movements. Otherwise, you’re just reinforcing or building bad habits, which as musicians, you know takes much longer to undo.
TRAIN AS YOU PLAY
As I alluded to earlier in my discussion, musicians also need to train their bodies in the positions they use to play. That involves identifying the correct muscle groups to help support/stabilize you and your instrument and strengthening in the correct manner. A LARGE portion of my work as a PT is to first make sure that your body is flexible/strong enough to work in the positions needed to play an instrument. Second, strengthening muscles in the correct manner - for violinists, that may mean isometric strengthening for the left shoulder, while concentric/eccentric strengthening for the left shoulder/elbow. Flutists would vary, and primarily focus on isometric strengthening for both arms. Every instrument has different muscular demands and should be respected. Last, for “sport-performance” training, challenge your body beyond the normal confines of playing while performing the functional exercises. The more versatile you are within this skillset, the more your body will be able to adapt in changing environments.
Last but not least....
BE YOUR OWN ADVOCATE:
FIND A HEALTHCARE PROFESSIONAL WHO WILL TAKE THE TIME TO LISTEN.
While I hope none of you end up in the situation that involves you having to go see a healthcare professional, make sure you take the time to find someone that will listen to YOUR story and put in the effort to work within your context. A good practitioner should work with you as part of a team, with you at the helm and in full control. This is regardless if they specialize in working with artists or not. Also know that you don’t have to have a problem in order to reach out for help. Talk to us about your questions and we are usually happy to equip you with the resources you need to become more empowered to take care of yourself and be proactive in your health journey.
The musician health movement has come a long way, but there is much more work to be done. I would encourage all musicians to invest the time to learn about how to care for yourselves and don’t be afraid to talk to each other about your challenges. Your body is your main instrument. Your musical instrument is merely a tool for you to create your art. If you are an artist, know that there are healthcare practitioners, like me, who specialize in working with performers and are dedicated to helping artists stay healthy and injury-free. And just like artists, we do it not because it’s just a job, but because it’s our passion.
Dr. Janice Ying is a Los Angeles-based Physical Therapist. She is board-certified Orthopedic Physical Therapy Specialist and is regarded as a leading expert in the field of Performing Arts Medicine and the development of cutting edge injury prevention and rehabilitation programs for musicians.
The information on this website is intended for educational purposes and should NOT be construed as medical advice. If you have or think you have a health-related issue which needs to be addressed, please seek the help from your local licensed medical professional.