Musicians' Health Collective

Musicians' Health Collective: Supporting the health of musicians (and normal people)

Demystifying the Piriformis

Image from wikipedia- you can see that each hip rotator has a different angle of attachment from pelvis to thigh, but they work together as a team to externally rotate the hip.

Image from wikipedia- you can see that each hip rotator has a different angle of attachment from pelvis to thigh, but they work together as a team to externally rotate the hip.

One of the questions I get somewhat often is, "what is up with my piriformis, and why is it bothering me?...and will yoga fix it?"  Truthfully, I don't know what's going on for you, but let's look at where the muscle is, and what its function is.  One of the key things to remember is that this muscle, the piriformis, works in concert with the other deep rotators of the hip- lying beneath the gluteals, and working to externally rotate your hip and assist in abduction in hip flexion.  This group of muscles attaches around the sacrum (tailbone) and attaches to the greater trochanter of your thigh bone, so essentially from pelvis to leg bone.  The other muscles in that group (super and inferior gemellus, obturator internus and externus, and quadratus femoris) all play their own role in similar actions, yet the piriformis is the only muscle in that group that is directly in contact with the sciatic nerve, the largest nerve in the body running from the lower spine all the way to the foot.  

Many of us have heard of, or perhaps experienced sciatica, which can manifest as numbness, tingling, burning, or other sensations in the foot, calf, and thigh.  The cause of the sciatica can be more difficult to pinpoint- a lower back pathology may be the cause, such as a herniated lumbar disc, and although the lumbar nerves blend together around the piriformis, the hip rotators are not always, though sometimes, to blame.  Sciatica is not actually a clear diagnosis- it doesn't tell you what the problem is, just that the nerve is being compressed somewhere from the lumbar spine all the way down to the foot.  In most people, the piriformis is adjacent to the sciatic nerve, but in some people, the nerves actually pass through the piriformis itself, which is where the issues can present themselves in pirifiromis syndrome if the muscle impinges the nerve.  A nerve impingement could still happen elsewhere in the leg or spine, but usually the piriformis gets the bad rap for causing impingement of the sciatic nerve.  Side note, the research suggests that the piriformis is only responsible for 6% of sciatic pain!*

So then what do you do if you have sciatica or believe you have piriformis issues?  I'm a big fan of seeing a medical practitioner to make sure other issues aren't present, such as a spine pathology or something else. As a yoga/pilates teacher, I can't and shouldn't diagnosis the cause of the pain, which is why it's good to seek a medical professional's opinion.  But if you google "piriformis stretch," or "yoga for sciatica," you will see a plethora of suggestions.  My main hesitation is that sometimes, stretching an irritated muscle or nerve will make symptoms worse, especially if it's not the culprit.  Yoga poses also aren't pills to fix things- a greater awareness of what's going on in the body is critical!  One of the things that has become more commonplace knowledge is that if something hurts, stretching it is not always a good solution and that lack of strength and stability may also be the issue.  Some questions to ask yourselves if you are having sciatic nerve issues:

1) Are the symptoms present in both sides of the lower body?

Image from Advanced Health Centers. You can see the sciatic nerve branching out around the knee as it travels down to the foot.

Image from Advanced Health Centers. You can see the sciatic nerve branching out around the knee as it travels down to the foot.

2) When are the symptoms most present? (sitting vs standing vs lying down, etc)

3) Do any movements relieve the pain? (i.e. does walking change things)

4) Do any movements exacerbate the pain?

5) How many hours a day do you spend sitting in a chair?

Musicians (and normal people too) spend many, many hours a day sitting in a chair, often at 90 degrees of hip flexion.  Even if sciatica or piriformis issues aren't present, the continued static position of the hip affects the whole body, including standing, walking, and other daily activities.  Lack of hip range of motion coupled with lack of hip strength can lead to issues within the whole hip and spine complex, not just the piriformis, so start by asking yourself these questions about what's going on in the spine, hips, legs, and feet.  

*By the way, there's a great blog on the whole "yoga and sciatica" conversation, and it's definitely worth a read!  

Finding the Root of Injury

Injury Categories.jpg

When we talk about musician injuries, we tend to think overuse: playing too much or misalignment, which is sometimes (but not always!) the case.  It can also be easy to blame oneself for such an injury, or to receive blame from others that your setup isn't good or that you didn't take breaks, or whatever.  This is not always the case!  In Elizabeth Andrews' book, "Muscle Management for Musicians," she outlines three different categories, which I've found helpful to look at and evaluate, both for students, teachers, and professionals.

Yes, this is real.  It's a contrabass flute.

Yes, this is real.  It's a contrabass flute.

1.  Musician Versus Instrument: This can mean the size and shape of your particular instrument (one viola vs. another) or having to play a lot of contrabassoon/bass flute/subcontrabass sax/etc. in relation to your normal workload.  This can also be as simple as pointing out that not everyone can reach the keys on a flute (without contorting one's hand) or that a full size string bass is not for most people.  There are an infinite number of ways to alter one's setup to potentially help support the body, and those changes definitely fall into this category.

2. Musician Versus Environment: This is a category orchestral players are certainly aware of- chairs, stand height, conditions of the room/space/concert hall, temperature, etc.  This can also include clothing restrictions (violinists in tuxedos, high heels for performance, or simple elevating one foot to play bass or guitar) or even carrying one's instrument.  For string players, this could also include the way one has to rotate one's chair or torso to share a stand, or the cramped sitting positions of the orchestral pit.

3. Musician Versus Self: In my mind this includes the other things we do that stress our arms, body, voice, spine, etc., which includes computer use, cell phone use, driving, standing (!), sleeping, etc.

I love Elizabeth's categories, and although I've altered the descriptions a bit to be more relevant, I think they're great points.  I would however, add a fourth category.

4. Musician Versus Music: Sometimes, even against your best intentions, the repertoire that you're studying, playing in ensemble, or preparing for an audition is too much for your body.  I've previously talked about how Paganini may have been hypermobile- for some folks, the extensions and left hand demands of the caprices are too intense and not practical.  This is true for a lot of contemporary repertoire in general- as our levels of mastery and virtuosity have skyrocketed, so have the demands of our pieces, often bringing near impossible pieces into the forefront of music.  (For example, some violists find the extensions in the Schnittke concerto to be too extreme.)  That doesn't mean that those pieces don't deserve study, they just may not be the right piece for you, or for you right now, or for you with your current instrument.  Another example might be an orchestra or opera company planning to do a Ring Cycle performance, which is a huge undertaking for any instrumentalist.  The rehearsal schedule alone might be very taxing, let alone the music itself.  Even if you're doing your best to take care of yourself, the repertoire, concert schedule, rehearsal schedule, or audition list might be too much for you, either now or in general. 

I've always been afraid of taking an opera orchestral job because of the challenges (physically and mentally) of playing cycles of Wagner operas.  Loud volumes, orchestral pits, and an infinite amount of string notes scare me!

I've always been afraid of taking an opera orchestral job because of the challenges (physically and mentally) of playing cycles of Wagner operas.  Loud volumes, orchestral pits, and an infinite amount of string notes scare me!

If you've been injured, reflect on what it was that may have caused or exacerbated the injury- which categories were applicable?  Having an awareness of these categories can certainly prevent future injuries, especially if you know what previously caused an injury.

What's a yoga/pilates/crossfit (etc.) body?

A few years ago, Pop Pilates/Blogilates creator Cassey Ho made a video with all of the criticisms she has received as a pilates and fitness instructor.  

A few years ago, Pop Pilates/Blogilates creator Cassey Ho made a video with all of the criticisms she has received as a pilates and fitness instructor.  

I'd like to take a small detour from music writing and general health things today to point out an interesting challenge I've noticed in the movement and wellness community.  In addition to various "fitspiration" type messages on social media and advertising, there's an inaccurate notion that a certain physical activity will inevitably lead to a certain physical and aesthetic appearance, i.e., yoga and pilates practitioners are long and lean in appearance (please let me know what that is if you figure it out), crossfit and weight lifters are strong and muscular, and so forth.  Couple that with some of the fitness slogans like "sweat is fat crying," and "don't stop until you're proud," and it can be difficult to know what to do.  This standard makes it even more challenging when you're a teacher of those disciplines and you don't fit the "image" of what a teacher looks like.

I love this campaign from the Yoga and Body Image Coalition.

I love this campaign from the Yoga and Body Image Coalition.

Here's the deal: every body responds differently to movement and diet.  Period.  Some people can eat junk food for years and be at a "healthy" weight, others might gain weight immediately with those eating habits.  Some people do crossfit diligently and don't necessarily become lean or jacked (which is why I love the blog Fat Crossfitter) and some people will immediately change physique.  Some pilates and yoga teachers are naturally tall and thin (or former dancers and gymnasts!), others are not.  In the world of fitness, there is this notion that there is a bottom line standard of lean and strong that we all can achieve if we only work hard enough, and if we don't have that body shape, then surely we must be doing something wrong, especially if we're a teacher.  A pilates body must surely be a thin one, right? And a yoga body is a flexible thin one? And someone who lifts weights must be strong and chiseled? 

I loved this fall issue of Pilates Style but was crushed to hear that Anula Maiberg was body shamed on the internet for her appearance in her article.  Take a class with her, and you'll see that she's smart and well informed, and more importantly, the classes are hard!

I loved this fall issue of Pilates Style but was crushed to hear that Anula Maiberg was body shamed on the internet for her appearance in her article.  Take a class with her, and you'll see that she's smart and well informed, and more importantly, the classes are hard!

We all have anthropomorphic differences that affect the way our bodies process exercise and diet, as well as hormonal, metabolic, and genetic differences, just as we have infinite variations of skin tone and hair color/texture.  Give a group of people the same workout plan and diet, and everyone's body will change (or not change!) differently and at different rates.  With a group of female fitness professionals between 30-50, you may have women with hypothyroidism or PCOS, women who have delivered multiple babies, women who may have chronic fatigue, women who have never been petite, and women who are happy and healthy at a different size than you.  And as a student or fellow teacher, you may judge a person for their body, but you don't know what's going on for them. (These folks are also business owners trying to make it work, independent contractors running around to teach, mothers, fathers, caregivers, partners, and more.)  For some reason, this seems to be ignored  in regards to fitness teaching-and it's preposterous.  In her awesome podcast, Pilates Unfiltered, Chicago based instructor Jenna Zaffino mentioned this very issue last fall. 

What’s a pilates body? It’s the body that allows you to function through your life with some joy, without pain, and lends itself to the fact that we’re working with individuals with a myriad of different experiences.
— Jenna Zaffino
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Why don't we look at movement as something more than a means of creating an aesthetic appearance?  What about how someone feels in their body? Or improving their quality of movement? So many of us have illnesses that affect our body, whether larger ones that affect our energy, immunity, digestion, or hormones, or smaller injuries.  Everyone has a different story, and not everyone should or can look the same, or achieve that "perfect lean" body aesthetic (especially if they've experienced body challenges).  Side note, everyone’s definition of bodily perfection is different, which doesn’t help! In addition, the training, meal management and dedication needed for figure competitions and athletic modeling is often intense and not sustainable long term for most people.  On the podcast "Behind the Podium," last fall, my friend and business owner Isabelle Barter said it best; "I am a movement educator. Some people are movement educators, some people are fitness models, some are both. But I am a movement educator."  As a teacher and professional musician, I've absolutely been judged for my appearance and body composition- 25 years of playing viola  means that I've spent a lot of time sitting in orchestras and ensembles (when I could've been exercising), coupled with some peculiar spine and shoulder challenges from adaptation.  (Oh, and I'm not a size 2, can’t do all the crazy yoga poses or advanced Pilates work, and that’s ok!). That's part of my body story, and everyone has their own story.  Judge me for my teaching and my knowledge, not my bodily appearance, especially not in regards to my movement ability.  In the fitness community, it can be tempting to assume that a teacher without a perfect body doesn't know what they're doing, but odds are, they're highly trained, extremely busy, and don't have the time or desire to work out for hours a day to achieve a perfect physique.  That doesn't mean that someone with a perfect body isn't worth studying with either, it just means that there is diversity of bodies within the greater movement community.  "The body that moves you throughout your life without pain and with joy" is the one you want to inhabit, not necessarily the one the magazines and media want you to.

Osteoporosis, and Why Your Bone Density Matters

About 54 million Americans have osteoporosis and low bone mass. It affects one in two women over 50! However, daily exercise and movement can help prevent low bone mass.-2.jpg

I recently went through the statistics for search queries on the blog, and one that came up was "violin and osteoporosis," which I thought was worth addressing.  We typically think of osteoporosis as something that old fragile ladies get, but frankly, it's something worth thinking about for both men and women, especially as we move past the peak bone density period of our twenties.

Simply put, osteoporosis is weakness of the bones, which causes them to be more brittle and susceptible to breakage.  The precursor to osteoporosis is osteopenia, meaning low bone mass.  Our bones are in a constant cycle of regrowth (ossification) and resorption (removal).  These two processes remain in balance throughout our youth, but as we age, there is often more resorption, and less ossification.  This is turn can cause a reduction in bone mass (osteoblast cells are less active than osteoclasts).

When I was at my doctor's office, I took a few pictures of this model spine, which shows a range of spinal issues.  Focus on the bottom three, (green, pink, and yellow), which compares bone density for osteoporosis (green), osteopenia (pink), and normal (yellow) bones.  Notice how large the porous surfaces are with the osteoporosis?

When I was at my doctor's office, I took a few pictures of this model spine, which shows a range of spinal issues.  Focus on the bottom three, (green, pink, and yellow), which compares bone density for osteoporosis (green), osteopenia (pink), and normal (yellow) bones.  Notice how large the porous surfaces are with the osteoporosis?

There are many factors that affect osteoporosis, from genetics, diet, and exercise, to hormonal levels due to cancer treatment, prescription medications, thryoid issues, or other endocrine dysfunction.  Osteoporosis affects one in two women, and one in five men, so this is definitely not a ladies' disease.  I became acquainted with osteopenia a few years ago when I was being treated for my pituitary adenoma (non cancerous pituitary tumor), which completely threw all of my hormones out of whack, essentially putting me into the hormonal cycle of menopause.  Our sex hormones (as well as the hormone thyroxine) stimulate bone cell growth and osteoblast activity.  This means that low estrogen and low testosterone negatively impacts your bone density, regardless of age or gender.  This also means that if you have a thryoid issue (most commonly underactive thryoid or hypothyroidism), and you take medicine to balance your hormones and TsH (thryoid stimulating hormone), you are also at risk because the meds you take may either overbalance or underbalance said hormones.  This is also true if someone has had hormonal treatment for cancer, i.e., hormone replacement therapy for breast cancer, ovarian cancer, etc.  Osteoporosis is a definite secondary risk from many forms of cancer and subsequent treatment.*

*Quick aside: before I was diagnosed with my tumor two years ago, I knew very little about endocrinology.  Now, a few MRI's, many articles, and many blood tests later, I know a bit more.  I highly recommend learning about your own health issues as much as you can, so that you can have dialogues with your doctor about medicines, side effects, long term care, etc.  It's made a HUGE difference in my treatment.*
This image is a bit more difficult to process, but do you see the shape of the vertebrae is actually different?  The top four vertebrae are all compressed, whereas the healthy bone on the bottom is normal shaped and the disc isn't compressed either.  The top two vertebrae are fractures (anterior wedge and compression) and green is osteoporotic and pink is osteopenic.

This image is a bit more difficult to process, but do you see the shape of the vertebrae is actually different?  The top four vertebrae are all compressed, whereas the healthy bone on the bottom is normal shaped and the disc isn't compressed either.  The top two vertebrae are fractures (anterior wedge and compression) and green is osteoporotic and pink is osteopenic.

So why am I discussing this?  Well, musicians (and frankly most people) tend to be sedentary (risk factor for osteoporosis) and our occupation forces us into a sitting situation for 6-8 hours a day.  Our peak bone density occurs in our mid twenties, which means that most of you lovely readers have already peaked!  As we begin to work towards our thirties, forties, fifties, sixties, and seventies, regardless of gender, we need to take care of our bones.  In addition, many musicians don't challenge their upper body strength out of fear of injury which doesn't help muscle or bone strength.  In looking at aging populations, one of the biggest risks is falling and balance, in conjunction with osteoporosis.  Hip, wrist, and spinal fractures are a serious risk which could put a musician out of commission for months to a year.  The good news is that bones also grow in response to mechanical stress, so daily exercise in a gravitational context (not swimming or cycling), walking, and weight bearing activities are really beneficial for your bones.  Osteocytes build bone in response to stress of 72 seconds (according to Dr. Loren Fishman), so for example, if you hold a plank for 72 seconds, you are hypothetically fortifying your upper body bones. If you do standing lunges, squats, and other body weight exercises, you are also fortifying your bones.  Since this is an isolating research study, I would imagine this applies to more dynamic movements such as walking, running, yoga, pilates, weight lifting, and all body weight activities. Biomechanist Katy Bowman writes that osteoporosis is not an all-body disease, but often restricted to specific location which also lacks movement and loading:

  • Ribs(This could serious affect breathing, which is a major issue!)
  • Wrists (If you're a musician, this is particularly scary)
  • Vertebrae (Hello, back issues)
  • Head of the femur (top of the thigh bone)

From a musician point of view, we want to keep our bones healthy and prevent fractures to our axial skeleton (spine, neck, sacrum, etc.)  Healthy bones permit a long lifetime of music-making.

Want more resources?

Katy Bowman has a few great articles on osteoporosis as well as a great podcast on bones.

Buff Bones is a great exercise program developed by Rebekah Rotstein addressing osteoporosis and osteopenia.

Jill Miller writes on Osteoporosis

Yoga For Osteoporosis in the Huffington Post: I don't love the demo pictures in terms of alignment, but the content is solid.

Why Astronauts Get Osteoporosis, by Brooke Thomas (Also interesting to think about in the context of the film Gravity, and why it wouldn't be possible for Sandra Bullock to swim/crawl/etc)

Shoulder Anatomy 101-Part 1

Shoulder Anatomy.jpg

The shoulders are a mysterious place for musicians and most people-Where do they start?  What the heck is a rotator cuff?  Is it a singular muscle?  And is there a shoulder joint?  It hurts when I do (blank), whats wrong with me?  I've worked with students and fellow musicians on understanding the basic mechanics of our shoulder and upper arms, which is an essential piece of knowledge for instrumental teaching and performance, as well as a healthy lifestyle for non musicians.

Basic fact #1: The shoulder is composed of three bones: the humerus, the clavicle,  and the scapula.  No more, no less.   The humerus is your upper arm bone (underneath your biceps and triceps), your clavicle is the collar bone running laterally from your sternum, and your scapulae are the wing-like bony structure on your back.  The glenohumeral joint (i.e. where your humerus meets your scapula and clavicle), is a ball and socket joint (meaning that your "shoulder joint" is in fact your glenohumeral joint).

Basic Fact #2: The rotator cuff is not a single muscle, but a group of four muscles.   When students or friends have a rotator cuff injury, they rarely know which one of these four muscles they've injured, which is actually a bit of an issue because they do wildly different things.  Here they are:

image from "Trail Guide to the Body," by Andrew Biel.

image from "Trail Guide to the Body," by Andrew Biel.

Supraspinatus: The top-most muscle, which helps to lift the shoulder, but does little in rotation.   

Infraspinatus: The middle muscle, which helps to externally rotate the shoulder, as well as adduct. 

Teres Minor:  The lowest muscle on the posterioir of the scapula also assists in external rotation and stabilization. 

Subscapularis:  This is sort of the ugly stepchild of the rotators-hidden on the front side of the scapula, towards the internal cavity, this muscle internally rotates the shoulder and is a major stabilizer.  It's also the largest of the group.

 

 

Basic Fact #3:  While massages can help remedy chronically tight shoulder and upper back tissues, you actually have to change the posture  or habit that is creating that tension pattern in order to see lasting change.  (I.e., if your shoulder rest makes your left shoulder elevate, you then get a massage, and then play the next day without changing anything, the effects won't last. The same would be true for your movement habits, yoga practice, workouts, etc.)  One has to combine soft tissue work with postural change and awareness to see results.  (Subtle somatic practices like Feldenkrais and Alexander technique can be great for that!)

More detailed view of the rotator cuff from "Trail Guide to the Body," by Andrew Biel.

More detailed view of the rotator cuff from "Trail Guide to the Body," by Andrew Biel.

Basic Fact #4: Your posture affects your shoulder mobility.  If you're a slumper, meaning that your upper chest rounds and your head pushes forward, you're at risk for many musculoskeletal issues, (not to mention unusual tension patterns related to being a musician).  Your shoulders can't move freely when your torso isn't supporting your upper body and you can't breathe as fully if your posture is compromised. 

Basic Fact #5:  Most people need to strengthen their rotator cuff, and most people (myself included) need to improve their upper body strength.  I find that many musicians are worried about destroying their upper bodies through exercise, which is a fair concern.  Yet, muscle atrophy is not helping anyone, and lack of movement aside from playing will be more detrimental in the long run. (Find a safe upper body workout, folks!). Swim, work with a personal trainer to figure out how to start a weights routine, take a yoga class with a teacher who will focus on your upper body alignment, try pilates-whatever floats your boat.

 

 

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