Threats to Healthy, Happy, and Safe String Playing
By Karin Dye
Photo by Joel Wyncott
Playing music can hurt.
You may know how to spot a violinist or violist friend from across the college cafeteria. They have a glaring red blemish angled on their left jaw (that you have suspected is probably infected), a tendency to ask anyone and their brother to “just really quickly work on a shoulder knot for them,” and a slight air of superiority; for they have practiced many more hours than you and they deserve some notoriety.
I remember in my college arranging course, our professor notified us that string players are known as the “workhorse” of the orchestra because in a typical symphony they play the most notes and have the least amount of rests. I think I audibly breathed a sigh of validation. Well of course I have pain, I’m a workhorse!
Who's to blame?
According to our good old friend Shinichi Suzuki, “clumsiness is the result of wrong-training” . Awesome, say we, so my kids have injuries and it's my fault because I didn't teach them properly.
Fortunately, we're absolved somewhat....we all know from experience that no matter how many times you ask them to straighten their wrist, they usually won’t work to change the habit until it starts hurting them. In a study to determine the average scope of knowledge music teachers possessed regarding music-related injuries I’m happy to report that, “the string teachers reported more opinions and were less unsure about injuries than were the keyboard and other teachers” . I’m unhappy to suppose that maybe this knowledge is born out of necessity since so many of us are experiencing pain. Womp, womp. That being said, acquiring some well-researched information is a good step in the right direction toward helping our students (and ourselves!). Before you go off and read multiple research studies because I know you are made of free time, wait! I have already done it for you.
PRMP, The Life For Me
PRMP (playing-related musculoskeletal pain) is the most common form of pain faced by violinists and violists. Musculoskeletal pain refers to pain in the muscles, bones, ligaments, tendons, and nerves (often caused by overuse).
As we teachers know, turning to the students themselves is often the best way to learn things. Through a series of self-administered surveys, a group of researchers from Université de Sherbrooke in Québec set out to learn from ninety-three bowed string instrument (BSI) players attending a summer music camp. The BSI players completed a questionnaire at the start of camp and then completed the same questionnaire again, seven days later. Participants illustrated their painful symptoms on a body diagram. The surveys found that “most BSI students in the present study (86%) presented with pain upon their arrival at camp, and almost all of them (96%) reported pain 7 days later."  I’m sorry, but are you kidding me? 86% of the orch dorks came into summer camp with PRMP and 96% left with it?? We have to ask ourselves if we are creating environments where students feel comfortable admitting pain to their instructors.
Why string players?
A 2002 study in upper-extremity problems in musicians  found that the repetitive motions are getting us down. Overuse. But overuse is common problem for anyone doing anything repetitively.
Why do bowed string instrument players experience playing related pain at a higher rate than athletes and non-BSI instrumentalists? The answer isn't quite as simple as the question, but in practical terms it's this: during musical performance (unlike other physical activities or how muscles are generally used in athletics), these muscles are repetitively performing at low forces relative to their maximum strength. Because of this, the muscles rarely become exhausted by high work intensity, which means that the player is unlikely to take as many breaks as someone with a higher work intensity .
Bowed string instruments players need to consistently be on the offense for these types of problems, because often times our bodies simply aren't asking us to take breaks until the injury has already occurred.
The Violin and Viola Hickey
If you are a member of the classical music community, you likely are familiar with the "violin hickey." Formally known as “fiddlers neck," the violin/viola hickey plagues many members of the upper string playing community. In a study solely dedicated to this neck blemish, researchers found that sixty-two percent of the 523 musicians interviewed had experienced fiddler’s neck, with a slightly higher occurrence amongst viola players (67%) than amongst the violin players (59%).
The researchers noted that many general practitioners, dermatologists, and surgeons would not be able to connect these lesions to playing the violin or the viola . And here I would like to take a hard pivot into the gas-lighting that is musician's pain. In my own personal experience of having plastic surgery to remove a hard cyst I developed from playing viola, the dermatologist and plastic surgeon informed me that this cyst was “unrelated to string playing and just coincidentally located in that portion of my neck.” It is important to note that many string players may not feel validated or that their “fiddler’s neck” is not a legitimate health problem. I went under the knife for the viola. Can I get some validation for that?!
TMJD, another life for me
Temporomandibular joint dysfunction (aka TMJD) sucks. If you haven't experienced it, yay! Skip this section. Or read on for the sake of your students. Think of the children!
In a 2008 study, forty-one violinists completed clinical questionnaires designed to detect bruxism and then compared their responses to a random control group who did not play any musical instrument. They found that while only 34% of the control group suffered from bruxism, 73% of the violinist group suffered from this. The researchers closed their study by expressing concern for upper string musicians and that they “believe it is necessary to establish specific treatments and health education programs to avoid the development of TMD among musicians”. If 73% of violinists with no known pre-existing playing-related injury were diagnosed with bruxism, I find it tragic that I’ve never seen this topic formally brought up in all my years of teaching and learning. I have personally suffered from TMJD since high school and did not know that it could likely be connected to years of upper string playing.
Pain and Mental Health
The physical pain of a music-related injury can also lead to emotional pain for musicians, as playing their instrument is their livelihood and their passion. Musicians experiencing pain are often made to feel that their pain is not valid. As Wilkinson and Grimmer (2019) explained in their study, “Unfortunately, musicians, like other workers, are sometimes viewed with skepticism when presenting with pain, possibly because of the relatively unexplored nature of the link between art and employment” (p. 58).  Plus a lot of musicians are afraid to stop and admit to injury.  As they say, psychotic breaks are just like coffee breaks! ...except you don't get paid for psychotic breaks. Musicians don't get paid if they're not playing.
This brought me back to my years running high school cross country. My coach NEVER wanted us to speak the dirty word...shin splints...because he thought that it eventually resulted in the whole team realizing new injuries. I see his point. And I will admit that I don't talk about playing related pain with much regularity in my classroom. I don't have many (if any) students currently with playing-related injuries. But I have to wonder if it is a "speak no evil, hear no evil" situation. Are some of my students in pain but are afraid to say so? If we began to discuss it with regularity, would more injuries present themselves? Well, I have no clue. But I think these are important questions to ask ourselves.
What now, ye of doom and gloom?
The lengthy list of threats to healthy, happy, and safe violin and viola playing is upsetting. But hey, it's 2020, and this is an upsetting year already so let's just go there. I believe that creating spaces for more open dialogues on these topics is important. Growing up playing violin and viola and existing in many musical communities, playing-related pain was not commonly discussed. When I entered college as a music education and viola performance major, I still did not feel very knowledgeable. My duet partner, a highly skilled violinist, spoke about scar tissue in her shoulder muscles as if that is simply what hardcore string players have. I assumed my pain was normal and something that came with the territory. After completing this review of emerging literature, I feel inspired to speak more about playing-related pain with my colleagues and students. Hopefully, slowly but surely, we can make changes to the orchestral culture around playing-related pain. The more we know, the more we can do to fight these threats to healthy, happy, and safe violin and viola playing.
So without further ado, here is a dorky little elementary strings video to drive home the importance of posture. I think developing healthy posture from the start is one of the best thing we can do for our students.
 Suzuki, S. (1969). Nurtured by love: The classic approach to talent education. Exposition Press.
 Quarrier, N.F. (1995). Survey of music teachers: Perceptions about music-related injuries. Medical Problems of Performing Artists, 10(3). 106-110.
 Robitaille, J., Tousignant-Laflamme, Y., & Guay, M. (2018). Impact of changes in playing time on playing-related musculoskeletal pain in string music students. Medical Problems of Performing Artists, 33(1). 6.
 Dawson, W.J. (2002). Upper-extremity problems caused by playing specific instruments. Medical Problems of Performing Artists, 17(3). 135.
 Wilkinson, M. & Grimmer, K. (2001). Ultrasound of the left shoulder girdle in professional violists and violinists: A pilot study. Medical Problems of Performing Artists, 16(2). 58.
 Blum, J., and G. Ritter. (1990). Violinists and violists with masses under the left side angle of the jaw known as “fiddler’s neck.” Medical Problems of Performing Artists, 5 (4): 155-60.
 Rodrigueze Lozano, F. J., Sáez Yuguero, M. R., Bermejo Fenoll, A. (2008). Bruxism related to violin playing. Medical Problems of Performing Artists, 23(1). 12-14.
 Bourne, D., Hallaran, A., & Mackie, J. (2019). The lived experiences of orchestral string musicians with playing related pain. Medical Problems of Performing Artists, 34(4). 198.