Tight shoulders, pains in the arms… is your body letting you down? Here’s physiotherapist Marion Turner with some exercises designed to help you fine-tune your mortal shell for a long and rewarding playing career…
Anyone who works with computers or in manufacturing with machinery can tell you all about aches and pains. Indeed, most of us have heard about Repetitive Strain Injury (RSI) and the long-term problems it can cause. We guitarists tend to overlook the intensely physical nature of the instrument because we become so absorbed in what we’re doing – and many of us only start to think about the side-effects when problems start to make playing more difficult.
If you want a happy and long playing career, then you’d better get guitar fit. But don’t panic; we’re not about to get you doing press-ups and star jumps. In this article we’ll be looking at possible long term problems, and helping you spot symptoms before they become chronic – and we’ve developed some simple stretching exercises that any player will benefit from.
Most of the problems that happen to guitarists are ‘overuse syndromes’, where the repetitive nature of playing the guitar causes problems in tendons, nerves and muscles – commonly the soft tissues of the body. The onset of any of these conditions can be attributed to many things: poor technique, poor posture, general lack of fitness, other medical conditions and external factors such as temperature, change of instrument, strings and so on. Being aware of the early warning signs of injury is paramount in the prevention of serious and chronic conditions. Do any of these sound familiar?
Signs to watch out for…
• Pain in the arms, hands or neck during or after playing or practicing.
• Restricted movement and/or swelling in the arms, hands or neck.
• Pins and needles or numbness in one or both hands.
• Weakness and reduced endurance.
• Changes in colour, temperature and sweating in the hands.
If you’ve got symptoms, you must start treatment early. Seek out professionals who specialise in the treatment of the upper limbs – and ideally in the treatment of musicians.
Some specific factors that may contribute to these problems are things that to some extent you can manage yourself. These include…
• Increase in time spent playing
• Change in guitar (or set-up) – a wider neck, heavier gauge strings, a higher action, the weight of the guitar, and so on
• Change in posture while playing – such as standing or sitting for longer
• Watch out for temperature: playing in a colder environment reduces circulation to
• Medical conditions: diabetes, rheumatoid arthritis and thyroid disease are among
those which can cause problems with your ability to play
• Change in work conditions – a new job with new physical demands, or more time spent on computer (this includes digital recording).
Some useful tips for injury prevention…
• Warm up and cool down with gentle stretches (see our stretching program).
• Take frequent breaks if possible – say, about five minutes’ rest every 20 minutes
• Don’t practice when you are physically or mentally tired. Fatigue leads to increased risk of injury due to poor technique
• Concentrate on maintaining good technique all the time
• Strengthen the spine. A strong spine will free up the arms to play rather than using them to support the instrument
• Move around while playing to reduce the effects of static posturing. Staying too still or using muscles in a small range of motion reduces blood supply to the tissues; this can increase muscle fatigue and lead to injury
• Build up your playing time gradually prior to a performance. Don’t expect to be able to play for three hours straight when you only practice for half an hour at a time
• Consider ergonomic aids and the set up of your guitar. Is your strap adequate? There are alternatives that distribute the weight of the guitar over both shoulders. Is the action too high? Can you use a more comfortable pick?
• Maintain good nutrition to enable the body to recover from playing. That also means drinking plenty of water
• Take up an activity that encourages good posture – yoga, for instance, or Pilates, or Alexander Technique
• Make sure you maintain/achieve a good level of fitness and control stress by exercising regularly. Walking is a good start. Meditation isn’t a bad thing, either.
The stretching program shown is a good starter for general warm up and cool down sessions. Take care to hold the stretches at the point where you just start to feel the stretch – not pain – and don’t ‘bounce’ while stretching. If any of these stretches causes real pain rather than a feeling of stretching, then stop and seek professional advice immediately.
Having discussed fitness, we’re now going to look at the five conditions most commonly seen in guitarists: thoracic outlet syndrome, carpal tunnel syndrome, tendonitis, cubital tunnel syndrome and focal dystonia. We mentioned that many of the physical complaints faced by guitarists are those that affect the soft tissues of the body. Well, fore-armed is fore-warned – so let’s look at the four most commonly-encountered conditions, and some ways of dealing with them.
Thoracic Outlet Syndrome
The thoracic outlet is the anatomical name for the area where the chest, shoulder and neck meet; major nerves and blood vessels pass through here on their way to the arm and hand. Thoracic outlet syndrome (TOS) is caused by compression of the major nerves and blood vessels in this area. It is usually felt as non-specific aching of the arm(s) and may be associated with fatigue or lack of endurance in holding positions and tingling and/or numbness in the hands during use. There may also be colour and temperature changes in the hand, such as going blue and cold regardless of the weather conditions.
In some cases, the presence of an extra rib (coming off the last neck vertebra) can cause TOS, but this is quite rare. Usually it’s caused by the nerves and vessels being squashed as they pass through tight muscles in the area, and it’s commonly seen in people with droopy shoulders. Over time, poor posture leads to changes in these muscles. Holding the arm in a forward or elevated position for long periods of time can cause problems, too.
TOS is often seen in guitarists’ fretting arms because of this forward positioning: the way the guitar strap comes over this shoulder area only adds to the compression.
If this is a problem for you, try a double shoulder strap, or a stand that takes the weight of the guitar when practising.
Generally, the symptoms come on when the arm is raised. You can check this out by holding both arms in the ‘surrender’ position (the shoulders and elbows bent to 90 degrees – see pictures above) while opening and closing the fists for 60 seconds. This test may reproduce the symptoms, but not always.
Similarly, nerve conduction studies, X-rays and vascular investigations do not always provide conclusive proof of TOS – making it a difficult condition to diagnose. In rare cases, surgery may be recommended – in the presence of an extra rib, the rib may be removed. Generally, however, it is posture and technique that will need to be modified.
Tight musculature needs to be stretched and the muscles of the upper back and shoulders need to be strengthened to support good posture. The eight stretches shown, particularly those for the pectorals and scalene muscles, are often recommended when TOS occurs. A health professional specialising in treating these disorders can give further advice specific to your condition.
Carpal Tunnel Syndrome
Carpal tunnel syndrome is a result of compression of the median nerve at the base of the palm of the hand in the carpal tunnel. The nerve shares this space with nine tendons; any change in size of the tendons or nerve in this confined space caused by swelling or inflammation results in the nerve being compressed.
This leads to pain in the hand (and possibly up the arm), pins and needles and/or numbness in the thumb, index, middle and sometimes ring fingers. These symptoms are often worse at night in the early stages, waking the sufferer from sleep. In more severe cases, weakness and general clumsiness (such as dropping things) will occur and symptoms will be present during the day. The guitarist will notice difficulty in performing fine finger hammer-ons.
To test for this condition, hold the index, middle and ring fingers out straight with the other hand while trying to bend the little finger towards the palm. If you are unable to bend it at the middle knuckle, release the ring finger and let them try together. If they can only bend together, there’s an interconnection present (sometimes the middle finger is involved, too).
Approximately 40 per cent of people have this anatomical variation on at least one hand, but it’s not usually a problem unless it’s in your fretting hand. If you have this variation, pushing yourself to perform techniques that you cannot physically do will inevitably strain the muscles and tendons.
• Relative rest
• Ice is useful in the acute phase when swelling is present. Apply for 10 minutes every hour to reduce swelling
• Anti-inflammatory medications
• Strengthening exercises for intrinsic muscles, finger extensors and the shoulder girdle plus gentle stretching exercises for the affected tendons/muscles as prescribed by a hand therapist
• Splinting, massage, heat, ultrasound, trigger point therapy and acupuncture
• Review of technique/practice habits
• Steroid injections
• Surgery is rarely required.
Trigger finger is felt as stiffness, pain, catching and, ultimately, the locking of a finger or thumb into the palm. The locked finger is generally seen first thing in the morning or after playing, and it can usually only be straightened out by pulling it back with the other hand. As the tendons pass down the fingers they run under bands that guide them, keeping them close to the bones.
These tendons run in lubricated sheaths to prevent friction as they pass under the bands. With repetitive use, the sheath and/or tendon can become swollen and sometimes nodules may form. The tendons then get stuck as they glide under the bands when the fingers are bent, and can’t pull back through. A snapping or popping sound is sometimes heard as the finger is straightened. Possible causes:
• Repetitive bending of the fingers – often those in the fretting hand.
• More commonly seen in people with rheumatoid arthritis, diabetes.
• Night splinting to keep the affected fingers straight
• Taking anti-inflammatory medication.
• Steroid injections
• Exercises (prescribed by therapist)
• Review of technique/practice habits
• Surgery – if there is no response to the above measures, the band may be released and/or the nodule removed.
In It For The Long Haul
If you’re serious about preventing injury and maximising your guitar playing life, consider your technique, your body and your instruments. Make playing safer by following these rules:
• When practising, take a five-minute break every 20 to 45 minutes
• Set up your guitar to make playing as close to effortless as possible (lowering the action, changing string gauge, etc)
• Distribute the guitar’s weight across both shoulders with a dual shoulder strap such as a Slider strap
• Use a stand while practicing Arm’n’Track, Efel Rest, or ErgoPlay
• Reduce the effort required in holding a pick (you could try F-1 picks and mounts – see: www.f1pick.com)
• Use a peg winder to change strings
• Strengthen the hands with products like DigiFlex, Gripmaster and FingerWeights
These accessories are aimed at preventing injury, as well as rehabilitation. They may be available at your local guitar shop.
If you have a problem already, then you should be assessed by your treating practitioner about the suitability of these devices for you. At the first signs of injury or discomfort, make sure that you seek treatment immediately.
Meanwhile, don’t forget to strengthen the shoulders and upper back with swimming, gym work, Pilates or specifically prescribed exercises from a therapist. Remember to include stretches in your warm up and cool down, and keep playing!
Our guitar health columnist is a physiotherapist with many years of experience in the rehabilitation and prevention of injuries. Over this time she has developed a particular interest in upper limb conditions, and many of her patients are musicians. With post-graduate qualifications in physiotherapy (sports) and membership of the Australian Hand Therapy Association, she has lectured at the University of Adelaide on injury prevention in musicians.