Cumulative Trauma Disorders and the Musician

What are cumulative trauma disorders (CTDs)?

CTDs are caused when there is sufficient stress in a tissue to cause a pathologic change in that tissue. Examples of common CTD injuries include: tendinitis, Carpal Tunnel Syndrome, fibromyalgia, synovitis, or bursitis. CTDs is the current name for a collections of symptoms which can be found in the medical literature occurring in musicians from as early the early 1800’s (Fry, 1986).

Since the 1980’s, a resurgence of interest in these disorders has led to new research into the specific demands that instrumental design, practice, and performance standards make on musicians. Thus far, classical musicians have been the main focus of these studies.

What causes CTDs?

The factors currently believed to be involved in CTDs are repetition, fatigue, force, frictional forces, static and awkward postures, vibration, and cool temperatures. “Repetition of motion, force of exertion, and type of motion (posture) are regarded as three of the primary risk factors” (Snook, 1995).

In addition, the occurrence of CTDs is not usually associated with one risk factor alone but usually due to a combination of risk factors (Silverstein, 1986).

Recognized aspects of injury with musicians

Practice time allows the musician to learn the technically fine and gross motor programs required to play the instrument. In the case of a musician, total playing time per day is the duration of exposure for possible injury.

Practice prepares and maintains the mind and the physical body for performance. Incorrect training and conditioning can lead to poor technique and cause the musician to be at risk for injury when playing passages of music that are too advanced or difficult for someone without perfect technique.

Even with a musician who is playing properly, if performance or practice time exceeds that which the body is able to handle without fatigue, they to are at risk for injury. Many musicians are on a rigorous performance schedule which allows inadequate recovery time between performances. This can cause fatigue and lead to injury.

Other than physiological strain, there is also psychological strain associated with performance. Musicians can experience stage fright or anxiety just as other performing artists do. This can be translated by the body into tension in the musculoskeletal system which puts even greater strain on the performer who is trying to give a perfect and emotionally moving performance. This type of stress can result in less control on the instrument and decreased endurance.

Another risk to performers is the requirement of some instruments that they be held in one place against gravity in order to be played. Static posturing can lead to fatigue and diminished venous return. The repetition of practice and performance can also cause repetitive trauma to weakened tissue if the body is not properly prepared.

The final aspects to consider with CTDs and musicians do not directly relate to the musician or his instrument, but to the actual everyday aspects of performance such as transporting the instrument and the work environment.

The repeated lifting of heavy instruments is a factor of the musician’s life which could also be the cause or an confounding factor leading to injury.

Likewise, the setting where the musician is required to perform may also be a risk factor for injury. Many times the lighting is so low that it may be insufficient when reading music. Also, in the club setting, the musician is subjected to the risks associated with second hand cigarette smoke.

Ideally, the musician should be positioned in a way that the viewing angle to see the music and the conductor is ergonomically sound. Many times performance spaces are small and cramped which does not allow the musician to move or position their instrument in a natural way. These indirect factors can result in fatigue and injury.

Practice tips to avoid injury

  1. Always warm up your body as an athlete would before a practice or event. Your muscles need a good warm up in order to function at their best. Begin with gentle stretches and playing passages of music slowly or begin with warm up exercises such as scales or arpeggios.
  2. Do not practice or perform when you are physically or mentally tired. Almost all CTDs are caused when fatigued tissue receives inadequate recovery and is forced to perform in spite of fatigue.
  3. Make sure that your technique and training is top notch. As a musician grows and the technical difficulty of the music increases, good technique and training are the foundation for continued ability to perform without injury.
  4. Approach a concert as a performance athlete. Determine the physical requirements of the repertoire. Then begin structuring your practice time to meet those requirements. For instance, if the music takes 20 minutes to play from beginning to end, don’t wait until the week before the performance to start playing the piece straight through from beginning to end without breaks.  Consider marathon runners: they systematically increase the number of miles they can run over a period of months in order to be fully prepared for the 26 miles the day of the race. Likewise, dramatically increasing the number of practice hours the week or two before the performance can cause increased fatigue and strain which can lead to injury.
  5. Allow your body to move freely to the music while you are playing. Static posture, and the requirements of some instruments to be held against gravity can cause fatigue in selected muscle groups and decreased time to recovery. Fluid movements of the head, neck, shoulders, and arms periodically throughout the piece will allow shared muscle recruitment and greater recovery time of fatigued muscles. This can decrease tension and increase blood supply to muscles required to work the most.
  6. While learning a new passage or technique, be mindful of the fact that the muscles are being asked to learn a new skill or pattern and will fatigue faster than if they were playing a passage which they had already been trained and conditioned to do. Therefore, avoid excessive repetition. Learn new passages slowly and gradually increase the tempo as the muscles become conditioned to requirements. Demanding that newly learned music be played quickly and perfectly is an unrealistic expectation which can lead to injury.
  7. Instrument transport. If you play an instrument that requires transporting it from site to site, this needs to be a part of your whole body physical training as well. For instance, a percussionist who must transport drums and cymbals from his home, in and out of his car, and in and out of concert halls must have a strong back and the upper body strength required for the lifting. Transporting heavy instruments home after a performance when the musician is already tired can be hazardous if that person is not physically fit for the hard lifting.
  8. Work settings should be designed to allow the musician to easily see his music as well as the conductor easily. Awkward positions, improper seating, poor lighting, as well as cramped performance spaces can cause a musician to play in an unnatural way on his instrument and this can lead to injury.

Do’s and Don’ts of piano posture

As stated before, awkward postures can themselves cause injury over time. Fortunately, many of these postures can be avoided. For example:

Don’t sit slouched over the piano with your head jutting forward and your shoulders and back rounded.


Do sit up straight with your head and shoulders upright.


Do play with your wrists and knuckles in the same plane with your fingers curved. This is a natural posture for the hand and similar to how it would be if it were just hanging down at your side.


Don’t cock your wrist to the side in order to reach for low notes with your left hand or high notes with your right hand.


Do keep your wrist in a neutral positions and move form the elbow and shoulder in order to reach the notes you need.



  1. Overuse syndrome in musicians – 100 years ago. Fry, J. H. Medical Problems of Performing Artists, 145, 620-625, 1986.
  2. Chronic Musculoskeletal Injuries in the Workplace. Ranney, D. Philadelphia: W. B. Saunders Company, 1997.
  3. Management of Cumulative Trauma Disorders. Sanders, M. J. (Ed.) Boston: Butterworth-Heinemann, 1997.
  4. Hand-wrist cumulative trauma disorders in industry. Silverstein, B. A., Fine, L. J., & Armstrong, T. J. British Journal of Industrial Medicine, 43, 779-784, 1986.
  5. Psychophysical studies of repetitive wrist flexion and extension. Snook, S. H., Vaillancourt, D. R., Ciriello, V. M., & Webster, B. S. Ergonomics, 38(7), 1488-1507, 1995.