The main way that musicians get injured is overuse.
If you understand how overuse injuries occur you can do two important things.
- Know how to prevent them
- Know how to handle them if the do happen
Luckily you don’t need a degree in biology to understand how they work. You just need to know a little about water and cups.
Here’s a 15 minute talk on how overuse injury works in musicians and how that informs what you can do about it.
Learn to Recover Better and “Build a Bigger Cup”
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If you prefer to read the transcript, here it is…
The Water and the Cup
So today, I want to present an analogy to help you understand the emergent ways in which overuse related pain and injury tend to occur. Once you have a better understanding, the ways in which you can reduce the risk of future injury, or rehab a current injury, start to become more obvious.
I’m going to try to keep in mind the Einstein quote “Everything should be made as simple as possible, but not simpler” as we go. So I’ll try to start simple and layer on complexity from there, but only to the point where it’s useful.
We’ll get into some detail, but I’m confident you can take it. After all, this is just a human physiology analogy, not music theory.
The Water and the Cup- Basic
So let’s dive in.
Picture a cup. The cup represents your body.
Now picture water being poured into the cup. The water represents all of the stuff that you have to do.
It turns out that this cup has some holes poked in the bottom. So imagine the cup with water being poured into it, and water draining out of the bottom. The water draining represents recovery.
So, the short and simple version of the analogy is that if more water gets poured into the cup than can be drained and the cup overflows, bad things happen. In the musician’s health case, this would be a playing related injury.
Just from this very simple version of the analogy, you can start to see how you may be able to impact the problem. Really you only have 3 options.
Option 1: Pour less water in. The most common “pour less in” recommendation is to just stop playing.
Option 2: Drain more out. I would argue that things like taking breaks, warming-up, stretching, getting enough sleep and other “self-care” strategies are all ways to help drain the cup.
Option 3: Get a bigger cup. This is essentially strengthening. Build your body so it can handle more of what you want to pour in.
That gets us started, but I think that we are still at a level too simple to be useful. Those are pretty general suggestions and I’m betting you’ve implemented some of them, but I think we have to go deeper to make it actually helpful.
Onwards then.
A Sophisticated Cup
Your body is no ordinary cup. It is a highly sophisticated cup with many features designed to help you keep it filled in an optimal range. Not too full. Not too empty. Just right.
So your cup keeps a close eye on how full it is. The most relevant fill levels are. Too low. A little too high. Way too high. Overflowing. Let’s take a look at each.
From an evolutionary perspective, too low was never much of a problem, so there’s really no mechanism to notify us that the level is too low. I would argue that not enough physical activity is a uniquely modern problem.
The problem with too low though is that if the fill level stays too low, the cup gets smaller. Our bodies are very efficient and there’s no use putting resources towards maintaining something if you aren’t using it. Use it or lose it as they say.
So too low is important, but when the cup is too low, we don’t get a warning. However we do get notifications for a fill level that is too high. I would argue that there are two types of notifications.
Picture your cup again. There’s the bottom of the cup, where fluid is draining out. A little ways up a line that represents too low. A ways up from there is a line where if the cup fills above it, a warning notification will get triggered. Then, a little below the lip of the cup is the final danger line, where if the cup fills above it, a danger notification gets triggered.
You may not feel it if the fill level is below the too low line, but when the fill level gets above the warning or danger levels you will definitely feel it.
From a physical perspective, I think of the warning notifications as feelings like stretch, tightness, fatigue, and stiffness.
The danger notification that pops up when the fill level is close to going over the edge is pain.
So again, the cup has lines for too low, warning and danger.
If you think about this, it’s a really useful system, especially when you think about it in terms of the overuse injuries that musicians tend to suffer from. You get lots of warnings before injury and tissue damage occur. You get lots of notifications that too much water is being poured in and not enough is being drained out.
I’m betting if you’ve suffered from an overuse injury, your body gave you lots of warnings prior to the cup overflowing. I’m betting you saw these warnings as something to push through and overcome rather than something to listen to, interpret and address.
It’s ok. We all do. I still do sometimes and I know better. When trying to perform at a high level you need to push things as close to the line as possible, without going over it. That’s really hard to do if you don’t clearly see where that line is. My goal in this analogy is to make that line more clear for you so you can make better decisions on how you approach it.
But that line is tricky. In fact, if your body decides it would be advantageous, the lines can move. To understand that, let’s talk about what happens at different fill levels.
What happens at Different Fill Levels
Pretty much everything in physiology deals with finding and maintaining an optimal balance. The technical term for this is homeostasis. So in this analogy, your body’s goal is to keep the cup filled above the “too low” level and below the “warning” level (and certainly below the danger level).
To achieve that goal, the size of the cup can change and heights of the warning and danger notifications can change as well.
As I mentioned a little earlier, if the fill level is too low for a while, you enter the use it or lose it realm. Gradually your cup becomes smaller.
If you pour in a bunch and the fill level goes above warning and above danger, then you feel pain. If you listen to this, stop filling and recover, then the fluid will drain out and gradually the pain will improve. The danger level will have effectively done its job by motivating you to take action and adjust the fill level accordingly.
If you fill the cup above the waning level, so you may feel things like stretch, fatigue, muscle burn, stiffness, tightness, etc, but below the danger level, then recover and let it drain back to below warning, and repeat this process several times over days, weeks or months, (so fill, drain, fill, drain, fill, drain) you’re giving your cup the message that more capacity is needed. In those times where you are recovering, the cup gradually builds itself up bigger.
This is obviously the process of strengthening. But in it you see that recovery is just as important as the work. The cup only gets bigger when the level is going down, not while the level is going up.
So what happens if you keep trying to do more. What happens if you fill the cup to above the warning level, but never let it recover. Well, your body wants to maintain that fill level homeostasis, so it is going to motivate you to change something. The best mechanism it has is through pain, so the danger level line will gradually shift downwards and pretty soon
From here, two things can happen. The first option is that you hopefully get the message, stop and recover. Drain the cup. It will take a little longer, but the danger line will gradually recalibrate back up towards the lip of the cup.
The other option is that you don’t get the message. You continue. You either push through the pain or do something to block the pain, like take some meds, and keep dumping more in. Well it turns out that having pain adds more to your cup. You may have experienced this. Being in pain is draining. It increases your muscle tension, so that goes in the cup. Your system is constantly in fight or flight, so that goes in the cup. You start having really negative thoughts about your future, so that goes in your cup. You do less of the things that help you recover and drain the cup. The danger line continues to plunge downwards, the fill level rises faster and faster. Eventually the cup overflows and now you have a big problem to deal with.
So now you should have a sense of how changeable the system is. The cup can get bigger or smaller depending on what the perceived needs are. And the thresholds for when pain comes on can shift as well.
Hopefully you can also see that the pain that you experience on the way to a full blown overuse injury is not a defect, it’s actually a defense. It’s there to help you and try to keep you out of trouble. If you will listen.
You’re also probably starting to see that what you put into the cup isn’t just physical activity. I think of what goes into the cup as any physical, emotional, psychological or social stressors. Not sleeping enough. Eating crappy food. Negative thoughts. Challenging life situations. Dealing with assholes. Emotional stress. And I could go on and on, but I think you get it. All of those things can fill your cup too.
On the flip side, positive physical, emotional, psychological and social experience can drain the cup.
It gets even more complicated, because some activities can have a dual “fill the cup, drain the cup” role and these can work very differently for different people. For some people, smoking can be an important way to psychologically drain the cup, but physically, smoking is really hard on your body, so it fills it at the same time.
Another example could be two musicians in a yoga class. One is really into yoga and has practiced regularly for a while now. To her the class feels gentle and restorative and the environment is comfortable and healing. The cup drains.
For the musician on the next mat, it’s a very different experience. Maybe she’s never done yoga before and it’s her first class and it’s a little too hard. Maybe she’s not comfortable with her body and she compares herself to the other participants in their yoga pants. She’s also self conscious that the others seem to flow so easily and she’s struggling. For her this is not a restorative experience. It’s stressful. It fills her cup more.
What if we change that second example just a little. What if the challenge of the class was perfect for her, but the psychological and social challenges were still there. Even though the physical side of it was perfect, the net result could be that the experience still fills her cup more than it drains it.
Body as A Collection of Many Cups
All of that is a long way of saying…it’s complicated. We’ve almost beat this water and the cup analogy to death, but there’s just one more piece that I want to add, because I think it might be helpful.
The last piece is that I don’t think your body is just one cup. I think it can be helpful to think of it as as a collection of many cups. Your finger may be one. Your left shoulder another. Your neck another. You get the idea. Perhaps your mental state is another. You can probably already see how if an overfull body-cup protects you with pain, perhaps an overfull mental cup protects you with anxiety or depression.
When you perform a particular activity, cup A may get filled more and cup B may get filled less. But if you perform a different activity cup B may get more and cup A may get less.
But what if you did lots of the first activity and not much of the second. Let’s say you do a lot of holding your flute in front of you, but not much hanging from the monkey bars. You’d do a lot of filling cup A and not much filling of cup B. Also, your body would get really efficient at that first activity from all of the repetition, so you get really good at filling cup A.
However, our bodies are resilient and adaptable, so we can actually tolerate this to a degree and as we just talked about, there are a lot more variables than just the activity that contributes to the cup overflowing. I would also argue that as a musician, this ability to fill one cup way more than another is not something to be fully corrected or made symmetrical. It’s probably part of what helps you play the way you do.
At the same time, this can get out of control. If cup B doesn’t get filled that often, it’s going to shrink. If cup A get filled too often, it can get into a state of being chronically over-full. If that difference goes too far or if it’s combined with a bunch of the other cup fillers, a problem can arise.
Luckily it’s possible to find your “cup B’s” and figure out ways to get better at diverting water that way, fill them and help get them bigger or at the very least prevent them from getting smaller.
In fact that’s a big part of my job as a physical therapist. A bunch of my exam is looking for areas that don’t hurt, but are underperforming, because these are opportunities to make things better.
Recap
By now, I’m betting your sick of cups, water, filling and draining. But hopefully it gives you a better way to interpret the sensations that you are feeling.
In short. Your body is like a collection of cups. Water being poured into the cups represents the physical, emotional, psychological and social stressors on your body.
Water draining out of the cup represents recovery, and this can be done through positive physical, emotional, psychological and social activities.
How activities fill or drain the cup is highly individual and some activities can do both at the same time.
Your body wants the cups to stay at a happy medium fill level. If the level gets too low for too long, the cup shrinks.
There are two high water notifications. One is a more gentle warning that typically presents as fatigue, stretch, stiffness or tightness. The other usually comes just before the lip of the cup and is a stronger danger notification that presents as pain (or anxiety or depression).
If you fill the cup above the gentle warning, but below pain, then let it drain, the cup cup will gradually get bigger and you will be able to put more into it before triggering a warning.
If you constantly pour in more than you can drain, the pain line will start to move lower in order to help you get the message that recovery is needed.
Experiencing pain dumps a whole lot more into your cup and the process can quickly spiral out of control.
If the cup overflows, then tissue damage and injury can occur.
Filling the cups doesn’t happen symmetrically and finding the cups that are chronically underused can allow you to find activities that help you get better at filling them and make them bigger, which can help you become more resilient.
Based on this model, hopefully you can start to see all of the different ways that you can either make your body more resilient to the physicality of playing, or recover from current pain or injury.
It may be a complicated, emergent problem, but it really it all comes down to either pouring less in, draining more out, or making cups bigger in a strategic and individualized way.