Musicians' Health Collective

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

Suzuki Turn-Out No More

Who decided that we should all stand with one foot forward and externally rotated?.jpg

     I started my humble music career as a Suzuki violinist, beginning at the age of 6.  While there are many useful and important things I learned in my early training, standing position was one that has posed confusion as I've aged.  Let me explain a bit more, for those non-violinist or violists out there.

This is a perfect example of learning "proper" violin stance.  Start with the feet together, then turn the feet out (externally rotating hopefully from the hip, hopefully) and then step the left foot forward.

This is a perfect example of learning "proper" violin stance.  Start with the feet together, then turn the feet out (externally rotating hopefully from the hip, hopefully) and then step the left foot forward.

When one learns beginning violin, often one is told to turn the feet out and step the left foot forward.  I learned this way, and stood this way for a long time.  (Over 15 years, at least).  A few years ago, I started noticing that in yoga, pilates, and weight training, we were told to have both feet pointing forward, at least sometimes.  I instead wondered, why do I always turn my feet out when I play, and does it actually serve me?  I have since started experimenting with this concept. 

This adorable image is from Shirley Givens' violin series, showing that left foot turnout.  In addition, the illustrated girl puts much more weight on her left foot, enhancing the asymmetry of the stance.

This adorable image is from Shirley Givens' violin series, showing that left foot turnout.  In addition, the illustrated girl puts much more weight on her left foot, enhancing the asymmetry of the stance.

So what's the big deal?  Our feet naturally point forward or with a minimal turnout, and you may already remember that when you walk with your feet extremely turned out, there are potential consequences for foot, knee, and hip issues.  (In addition, when feet point forward rather than externally rotated, the musculature of the foot is better able to support the body in standing and walking, and the ankle joint is able to articulate more fully.)  From a biomechanical perspective, I don't understand why music educators have been teaching students to externally rotate their hips while standing, and I definitely don't understand why one foot needs to be in front of the other.  I just don't.  (Who decided this was a good idea?)  However, I don't only care about the feet, but I care also about what is happening in the hips too.  When one hip is perpetually externally rotated (left hip), we can exaggerate that asymmetry out of the practice room, and in our daily walking, standing, and movement lives, even if we don't intend to.  That means that one set of external hip rotators is constantly working more than the other set, which can affect the muscles, bones, and connective tissue over time.  What does that mean? 

See how the right side is higher than the left?  Mine is the opposite-my left side is shorter than my right.  Pelvic tilt Image from http://medical-dictionary.thefreedictionary.com/

See how the right side is higher than the left?  Mine is the opposite-my left side is shorter than my right.  Pelvic tilt Image from http://medical-dictionary.thefreedictionary.com/

Side note, I came to this conclusion because of certain issues I was having in my hip, and that I was seeing in other colleagues of mine.  Here are some of my personal symptoms, which may or may not be yours:

1. My left hip has consistently turned out more than my right, whether I'm in music mode, standing, cooking, walking, running, etc. This can simply manifest as the foot turning out, at least in appearance. Both hips want to turn out in standing though.  I've been working on gently bringing the legs back to neutral, and found that to be helpful.

2.  This in turn can cause my left external rotators of the hip and the low back muscles to be unruly.  (Muscles include my gluteus medius, TFL, Quadratus lumborum, and the iliotibial band of fascia.

3.  I also have the beginnings of a baby bunion on my left foot which may be impacted by the external rotation of the hip.

4.  From a combination of asymmetrical music-making, left side dominance, and a host of other things, my entire left side is loads tighter (less range of motion from sole of the foot up to the shoulder!) than my right, which means that I sometimes have back pain and other issues on just the left side.  

So what's the solution?  Start to get curious. It's also important to remember that correlation does not imply causation- my left hip/back issues aren't inherently caused by the turn out, but I would venture to say that the perpetual external rotation has impacted things.  I will say that my pain has diminished exponentially since I've been doing pilates and other movement activities that have challenged my hip range of motion and stability.   

Ask yourself:

-How do you stand when you're playing? Where are your feet, knees, and pelvis?  What sort of shoes do you normally wear?  How might those be affecting your lower body?

-How do you teach your students to stand?  If you have a specific way of teaching stance, why do you teach what you do? 

-Try standing differently.  Maybe feet closer together, more parallel, right leg in front, both legs in the same orientation...give yourself permission to experiment, and perhaps that will change how you teach.

-Do you sit when you practice at home, and if so, what are your legs doing?

-If you photograph yourself (or video) while playing, what does your standing look like in context?

-Do your feet turn out when you walk/run/play/sit/etc?  Start experimenting with changing that setup gradually and see if it changes how you feel.  It can have ramifications all around the lower body, specifically feet/knees/hips/spine, but maybe affects other aspects as well.

Playing an instrument requires movement within the body- it's not meant to be a static endeavor, but repeating the same position in perpetuity for twenty plus years may not be the best.  

 

Running Recovery

This past weekend was one of the big marathons in my area, and watching people finish made me glad that I did not in fact participate, and more importantly, made me think of ways that runners might recover after such a race.  Here are a few of my favorite videos for self care after a race:

I love a little bit of rolling for center of glutes to prime your hips for daily life, but also to manage any overuse.

This is a video from friend and colleague Alexandra Ellis which goes through the 90/90 stretch, or the pinwheel hips of the mermaid in pilates.  It can be easy to neglect external and internal rotation when training for a race, and this is a good movement to add to the traditional work.

Lastly a quick calf roll out with a therapy ball, tennis ball, or softer ball can help restore foot and ankle movement.

Help- I Have a Nerve Entrapment!

While musicians may not know exactly know how nerve compression works, we may know the physical sensations or have heard of them- numbness and tingling in the fingers, an inability to hold things or grip them, and sometimes tendonitis as well!  Nerve entrapment is when a nerve becomes compressed by surrounding tissues or irritated from sustained holding positions, misuse, overuse, etc.  For musicians, there are three nerves of the upper arm which are often affected: the radial nerve, the ulnar nerve, and medial nerve.  These nerves originate from the cervical spine and top of the thoracic spine  (aka. they start in the neck and upper back), move through the brachial plexus, and can be affected by movement patterns, lack of blood flow, tendonitis, etc. along the way to the hand.

The two most common areas of nerve entrapment affect the ulnar nerve via the elbow and median nerve via the wrist.  Carpal tunnel syndrome refers to the area in the wrist where nerves and flexor tendons pass through to the hand.  Tendonitis and inflammation in these flexors can press on the nerve, which might be caused by overuse, misalignment in technique, or repetitive trauma.  This could be because of how a student holds his or her instrument or bow, how he or she plays at the piano, or even types at the computer.  For string players, extreme wrist extension (elevated wrist when holding bow with fingers below) can also accelerate these issues. 

Cubital Tunnel Syndrome affects the ulnar nerve, and refers to the cubital tunnel in the elbow region where the nerve passes to the ulna.  The ulnar is the largest unprotected nerve in the body, meaning that it has very little soft tissue and muscle to protect it.  Each time you bend your elbows, your ulnar nerve is slightly compressed which is normal, but sustaining bent elbows for many hours a day can wreak havoc on this sensitive nerve.  Most musicians need to bend their elbows to 90 degrees to simply hold their instruments, and then add to that driving, computer use, eating, and sleeping, which can equal 20 hours of bent-elbow motion a day!  Also factor in that oboists and bassoonists will make reeds, most likely with bent elbows and sitting over a reed desk.  Compression in the ulnar nerve may lead to numbness and tingling in the pinky/ring side of the hand as well as the ulnar side of the forearm.

Lastly, radial nerve compression will affect the thumb side of the hand.  (Remember last week's radius vs. ulna mini anatomy lesson?)  This can occur in the elbow as well, though it will be in the inner pit of the elbow, unlike the ulnar nerve.  There can also be compression as the nerve travels into the hand, along the thumb side.  Excessive pronation, bow gripping, and over-gripping an instrument, can contribute to these issues.

Now this may look rather bleak, especially when nerve compression is coupled with surrounding tissue inflammation or tendonitis, but we'll take a look at some prevention strategies next time, as well as common treatments.




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Fascianating! What's the big deal with fascia, and should you blast it?

    I sometimes neglect a key part of understanding our body's soft tissues in an attempts to focus on muscle and function.  Which tissue am I referring to?  Fascia.  While you may not be familiar with the complex and interesting properties of fascia, you have certainly heard of it in terms of feet: plantar fascia, or the fascia of the thigh: tensor fascia latae.  Fascia is controversial, or as controversial as a soft bodily tissue can be.  Some scientists and researchers completely discredit its ability to affect mobility and muscle movement, whereas others are deeply entrenched in research on how it affects body motion and how it creates structure and form in the body.  I happen to be pro-fascia, if that's possible, and I do believe that certain philosophical tenets of fascia research are incredibly valuable to looking at the whole person in regards to tissue injuries and pain.  (As a reminder, I am neither a doctor nor a scientist, many of whom can more thoroughly explain these concepts.  This is merely my understanding as a musician and movement instructor.) Let's backtrack, though.

If we imagine that the peel is our most outer casing, we can see all of this white fibrous material which gives structure and organization to the fluid within.

If we imagine that the peel is our most outer casing, we can see all of this white fibrous material which gives structure and organization to the fluid within.

What is fascia?  Fascia is the soft tissue component of connective tissue (as opposed to nervous, muscular, and epithelial tissue)- there are many different types and textures of fasciae, from superficial to filmy to deep, interwoven around muscle and encasing organs.  Superficial fasciae surrounds all of our body much like a silk stocking, but tendons, ligaments, and even vertebral discs are considered part of the fascial system.  A great way of understanding this is looking at a grapefruit or an orange (thank you Tom Myers for the image).  The peel is akin to our skin and adipose layer, and when you remove it, there is an abundance of white pith, structural fibers, and casing around pockets of juice, AKA. the fruit.  Without the pith, there would just be a mess of juice inside the peel but with the pith, there is individual encasing and structure for the whole fruit, giving it a fibrous and juicy texture.  Over time, as the fruit ages, the pith and skin become less supple, and one may need to roll the fruit on a surface to restore some fluidity to the juice.  Most types of manual bodywork attempt to restore some of more fluid capacities of our fascial system, as we too are a fluid system (not fluid meaning like a waterbed, but fluid like a hydrated sponge).

Fascia is our body’s aqueous soft tissue scaffolding; It provides the matrix that your muscle cells can grow upon and it also envelopes, penetrates and surrounds all of your joints.
— Jill Miller
When you bisect the orange, you can see the geometric organization of the fibers, as well as the asymmetry and the random bulge in the right.  While we are not divide into segments like this, the structural binding is very similar.

When you bisect the orange, you can see the geometric organization of the fibers, as well as the asymmetry and the random bulge in the right.  While we are not divide into segments like this, the structural binding is very similar.

Why is this relevant?  Well, I have been absolutely guilty of exposing one or two muscles at a time, in conjunction with related bones as a way of demonstrating function and location, whether for blogs or for my yoga and pilates classes.  Yet, fascia underpins the entire structure of the body, meaning that no muscle, no movement, and no body part is an island.  While anatomy books may cut out everything but a deltoid to demonstrate certain aspects of its properties, the deltoid is truly part of a web of myofascial structures operating as a team, and in order to assess injury, limitation, and range of motion, one has to look at the whole body.  In addition, when your fascia is restrictive or your muscles are "tight" or perhaps lacking full range of motion (PS. "tightness" is an experience not a technical movement term), there can be an adhesion against the fibers, which can additionally cause discomfort and restriction in the area.

This is an image from Dr Jean-Claude Guimberteau's Strolling Under the Skin, which takes a look at living human fascia!

This is an image from Dr Jean-Claude Guimberteau's Strolling Under the Skin, which takes a look at living human fascia!

As musicians, most of us assume an asymmetrical position to play our instruments (or sing, or type on the computer or drive or write), and our myofascial system adapts in accordance; something called adaptation, and sometimes adaptive shortening.  For example, as a violist, I have less range of motion in one of my shoulders from 24+ years of asymmetrical music making, but is it exclusively muscular shortening?  Definitely a combination of many different connective tissues adapting to the input I gave it, through the process of mechanotransduction!  While that is perhaps scary to think of, it also means that the body and brain are plastic, and that change is absolutely possible, both fascially and neurologically.  It also means that addressing the fascial system is KEY to healing from an injury, or simply improving performance.  

 

In Gil's talk, he discussed how fascia is stronger than we ever realized before, and that the health of the fascia profoundly affects the function of the structures it surrounds.  

In Gil's talk, he discussed how fascia is stronger than we ever realized before, and that the health of the fascia profoundly affects the function of the structures it surrounds.  

How is this different than other approaches?  Nowadays, Western medicine is focused on specialists-we have nerve specialists, hand specialists, orthopedic specialists, etc.  The catch, is that if you have nerve entrapment in the elbow, which affects your motion in your hand, you will be sent to all of these different specialists, without taking an integrated viewpoint of the big picture.  (i.e. you have may have nerve entrapment due to your motion patterns, as a result of injury to one shoulder, or to a poor setup in sitting with your instrument, or a compensation pattern, etc. etc.)  It can be incredibly frustrating to be in this situation, especially when no one can diagnose your ailment effectively, or when no one can treat your condition completely.  Many types of holistic practitioners, be they osteopaths, acupuncturists, physical therapists, chiropractors  etc, look at the whole picture of the body's wellness as a reflection of one area of sensation.  (Side note, holism is looking at integrated health, reductionism is the traditional western medical approach.  Both have their place, but many medical professionals are now looking beyond reductive means to find solutions).   This is in line with the idea that the whole body is fascially continuous, which means that an issue in the foot or ankle can affect the hip, knee, or spine, but not just on a muscular or neurological level.

Image courtesy of AnatomyTrains.com.  The first image questions the dissect and separate logic of traditional study, and the second explores the more integrated idea of fascial webbing.

Image courtesy of AnatomyTrains.com.  The first image questions the dissect and separate logic of traditional study, and the second explores the more integrated idea of fascial webbing.

I'm still confused.  How does this affect me again?  Many injuries start with the health of our fascia, the hydration level of the tissue, and the ability of the layers of myofascia to slide and glide against each other.  When our fascia is dried out or brittle, we are at higher risk for injury, and our capacity for proprioception, or bodily awareness is diminished. *An article by Tom Myers of Anatomy Trains proposed that there are 10 TIMES more proprioceptors in fascia than in muscles!  As musicians and movers, proprioception is our portal to movement quality, movement efficiency, and increased performance, whether in daily activities, musical activities, or athletic performance.  Your movement choices, or lack thereof affect your fascia profoundly!  Also, scientists are discovering that fascia is significantly stronger, more malleable, and impactful than ever thought before- it used to be something discarded in dissections, and it's way more than that.  It affects the muscle system more than we realize!

The Fascia-Blaster.

The Fascia-Blaster.

Healthy fascia benefits from diverse, varied, and frequent movement, as well as manual therapy (or tool assisted therapy).    A bodyworker can also help to expose issues in your myofascial web (myofascial meaning muscle+fascia), whether that be through myofascial release, rolfing, etc. 

Should I be blasting my fascia? Ugh...well, I'm glad that the fascia- blaster made the word fascia mainstream, but I'm pretty against the fascia blaster.  In case you don't know, the fascia-blaster is a "tool" that attempts to rid the body of cellulite via a hard plastic self inflicted torture device.  The first part I dislike about the fascia blaster is that it demonizes fat and cellulite, which isn't helpful.  It makes money by shaming people (often female identifying) about their bodies.  Your fat layer is your superficial fascial layer, and yes you can change it based on diet, exercise, etc., but there's nothing wrong with having one to begin with, and the goal is not to get rid of all your fascia or superficial fat.  I always bristle at schemes intended to have dramatic before and after images, and to say "thin is better than whatever you are now."  Oh, and don't forget that the product can cause bruising and other severe reactions- yes, your cellulite will be gone if you bruise it up, but it will probably return once those bruises heal.  Don't worry, I had a thigh master in the 90's and an ab roller as a teenager, so I've tried that seen on TV $#*%.  The founder of the implement doesn't have any professional training as a medical professional, bodyworker, or movement trainer (or at least none of her credentials are listed...anywhere).  At the end of the day, I'm just sad that people are beating themselves up with a hard plastic implement that causes bruising because of cosmetic reasons.  (Softer stress transfer mediums are great- not lacrosse balls or blasters, but softer balls, squishy balls, rubber balls, etc.)  Love your fascia, treat it kindly, and it will move you well.

I had the opportunity to hear Gil Hedley in Austin, and he dropped some excellent truth bombs about fascia.

I had the opportunity to hear Gil Hedley in Austin, and he dropped some excellent truth bombs about fascia.

Want to know more?  I'll definitely post more on fascia in the future, but some of the leading scholars in fascia are Robert SchleipTom Myers of Anatomy Trains and Gil Hedley of Somanauts.  I also really like Brooke Thomas' blog, The Liberated Body, and her respective Ebook.

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