Avoiding and Recovering from Left Hand Injuries                                     by Jeffrey Irvine
 

Viola Forum Column of American String Teacher, Summer 1990.
 

Experiencing an injury to one's left hand or arm can be a frustrating and difficult experience for any violist. Violists do not suffer these injuries with any more frequency than any other string players, but in a certain sense our instrument puts more strain on our left hands than the other string instruments. We play tetrachords between our 1st and 4th fingers with bigger spaces between our fingers than on a violin. Cellists and bassists, of course, do not usually play tetrachords between their 1st and 4th fingers. How we deal with this spacing is one of several factors that are important in maintaining our playing health and the playing health of our students.
 

Before I get into more specific left hand ideas, let me state a few of the basic principles for prevention of injury that have been stated many times before by the various researchers in the field, but are nonetheless worth repeating.
 

1.            Warm up before practicing or playing! There are many different ways to warm up and the same warm-up routine will not work for every violist. Warming up could involve playing open strings or slow scales or it could involve stretching or moving exercises away from the viola, or many other possibilities. Each violist needs to find a routine that works for him or her. (I have recently run across a wonderful paperback book called Stretching by Bob Anderson, published by Shelter Publications).
 

2.            Don't suddenly increase the amount of time you're playing per day. If you have been playing about an hour a day and you suddenly start playing five hours a day, you're putting a lot of physical strain on yourself. Again, each violist needs to learn for him or herself how quickly you can increase your playing time, but adding no more than a half hour per day should prevent this kind of injury. If you're recovering from an injury, you might be able to add only five minutes per day to your practicing time.
 

3.            If you decide to change something in your technique, do it in a planned, gradual fashion. A shift of left hand position, a new shoulder rest, an attempt to unlock a stiff right thumb - all of these things use new or different combinations of muscles, tendons and ligaments, and our bodies need time to adapt. This might mean using the new technique during only part of your practicing time, or else decreasing the amount of practicing time (and/or breaking it up more), then gradually building back up to your normal  amount.
 

4.            Exercise regularly to keep yourself in good physical shape. Aerobic exercise develops reserves of energy, contributes to feelings of confidence and well-being, and maintains general muscle tone. All of these factors can help prevent injury. Swimming is especially helpful for string players because it utilizes the upper body and because the buoyancy of the water prevents undue strain.
 

5.            Maintain good body posture while playing. Slumping shoulders, locked knees, and outstretched chins can lead to excess strain, tension and injury.
 

6.            Do not encourage "all or nothing" attitudes among your students, especially those who are already "overachievers." Of course we should all encourage and expect high standards, but for those students who face significant pressure to achieve from home, and who equate achievement with self worth, strong pressure to succeed on their instrument can lead them to excess physical tension and injury. Let them know that you accept and support them even if they don't get that I rating at contest. For the student who has good intonation but is devastated because they missed a shift in a performance, teach them that we all make mistakes and that there is no such thing as a perfect performance. I realize that students like this are in the minority, but they are probably the students who suffer the majority of injuries.
 

There are a few specific principles and exercises that will help in preventing injuries to the left hand and arm. The most important of these is to use only the effort necessary to push the string to the string to the fingerboard, and no more. The pincer movement between the thumb and the fingers is one of the most common causes of injuries in violists. Being a teacher of college students, most of the work I do in this area is remedial, i.e., loosening up the grabbing of the thumb and the over-pressing of the fingers that is already ingrained in these violists. One of the important tools that I use to help these students loosen their left hands is to have them play with their fingers touching the strings as if they were playing harmonics on every note. In other words, they are not pressing the strings down, just touching them. I do this first on simple scale patterns and then on passages from their repertoire or etudes.This should be done with normal arm weight and bow speed, especially in strong passages. Students (and many professionals) often press too hard with their left hand when playing strongly, and they must learn to relax their left hand when playing strongly. The student should also vibrate gently while doing this if the passage warrants it. This exercise produces a terrible sound, so it is useful to demonstrate it to the student so that they know its alright to make a sound like that for the purpose of the exercise. The next step is to have the student play the same passage while allowing the fingers to fall to the fingerboard, stressing that they should only use enough weight to get a good sound, and no more. Again, they should aim for the appropriate bow color for that passage. For students who have a lot of trouble letting go, one might have to start them off with a very soft bow sound, or add an intermediate step of pressing the string half way down.
 

This whole process should be done on a couple of phrases, especially those phrases that the student reacts to by squeezing. The most helpful step, however, is to incorporate this method into bigger sections and whole movements by playing "harmonics" for only a few notes per line, while playing with a normal sound and finger weight the rest of the time. By doing this the student continues to remind him or herself of how little effort one needs to make one's left hand work beautifully.
 

For most students, this method seems to relax both their thumb and their fingers, along with the rest of the hand and arm. (Some of the muscles involved in the "pincer" movement of the thumb and fingers originate in the elbow. Pains or numbness in the elbow, the forearm (palm side), and the wrist, are often caused by this pincer movement.). For some students who are inveterate thumb squeezers, the "harmonic" method isn't enough to get them to let go of their thumbs. For them, the next step is to have them play without their thumb. As they do this, hold their scroll up for them, and have them rest their viola on a stand when they're practicing this way. They can also try playing with "harmonics" while they're keeping their thumb away from the neck. Again, try this for a phrase or two, then alternate with the thumb in a normal but relaxed position and the thumb away from the neck for a few notes. Hopefully this will remind the student that you don't need to squeeze with your thumb to play the viola.
 

The 1981 Summer edition of AST included an article that I wrote with Dr. William LeVine entitled "The Use of Biofeedback to Reduce Left-Hand Tension for String Players." I still use those methods for students who have an especially difficult time relaxing their left hands and would refer the reader back to that article if you're interested.
 

A tight vibrato is also something that can lead to left-hand tension, but that subject needs an article of its own.
 

Another aspect of the left hand that sometimes leads to injury is the rotation (or lack of it) of the hand and arm from string to string. Imagine a student playing on the A string and then moving to the C string without rotating the hand or arm. This puts tremendous strain on the back of the forearm (the side opposite the palm), and is often the cause of injuries or pain there. This problem can be related to squeezing with the thumb, because that squeezing can inhibit the free rotation of the hand and the arm. Of course, an exaggerated rotation is not good either. Rotate just enough to balance the fingers over each string.
 

All of the strains I've talked about so far can be at least partially related to the finger spacing problems that I referred to at the beginning of the article.The best way to deal with these problems is to allow the hand and the arm to balance over the finger that you're playing. Each finger must have its own balance. This means that you should have only one finger down at a time, except when you're playing double-stops, trills, or alternating quickly between two notes on one string or two strings. This is not to say that the fingers should be flying around (which I think is caused by excess pressure and tension, not by inherent "unruliness" in the fingers) or that you should forcibly lift them up when it feels more natural to keep them down, but rather that you should allow the balance of the hand to glide from finger to finger. Anytime you hold down more than one finger at a time, you increase the amount of tension in the hand. Some violists with small hands may even need to have two "first positions," one for finger patterns with more 1st, 2nd and 3rd fingers, and one for patterns with more 3rd and 4th fingers. Of course, the faster the tempo, the less the balance will change, and the more it will be an average between the fingers you are using at the time.
 

These last ideas may be the most controversial of this article, for I know that some teachers feel your intonation will be better if you hold down fingers that you aren't playing and/or hold your fingers over the basic tetrachord.I must disagree because I think that our kinesthetic sense measures the distance to the next note as the finger moves towards it. Holding the previous finger down does nothing to improve the intonation of the note already found, or the next note, which we measure from the note we're on. Holding extra fingers down means more tension in the hand and makes it harder for the hand to flow from one note to the next.
 

These are a few of the ideas that I use in my teaching for reducing left-hand tension and preventing injury. I must give credit to teachers and colleagues for the genesis of many of these ideas. If you or your student do develop pain in your left hand or arm, these same ideas can be helpful, but with the following steps in mind.
 

1. If something hurts, stop playing!  A simple rule, an important rule, one that should never be violated except in a concert. For professional orchestra players, this rule may be more difficult to follow, but let's hope that managements will continue to become more enlightened.
 

2.            Let the pain go away before starting to play again.
 

3.            Determine what caused the pain and fix the problem. How? Retrace your steps. Did you play a lot more than you were used to? Did you make a technical change too quickly? Were you driving yourself so hard towards an audition or a competition that you tied yourself up in knots? Are you pressing too hard with your fingers or your thumb?
 

4.            If the pain lasts for more than a couple of days, consider seeing a doctor who specializes in the medical problems of musicians. Doctors who specialize in this area have learned a lot in the past ten years, and will most likely be very helpful. The trend these days is towards conservative, non-invasive treatment, a trend I wholeheartedly support.
 

5.            As you start to play again, play with "harmonics" for a substantial percentage of the time. This puts very little strain on anything in your left hand or arm, but still allows you to get your fingers moving again. I don't recommend practicing without your thumb when recovering from an injury, because if it's done wrong (tensely), you can strain yourself further.
 

6.            Feel the motion of your fingers coming from the base knuckles. This will help the fingers move freely and easily, whether they're playing normally or just touching the string. Feel your hand flowing from finger to finger.
 

7.            Start out with much less playing time than you are used to. Take frequent breaks and divide up your practicing into several periods. Day by day, add a little more practicing time. If your pain gets worse, you know that you've done too much too soon or that you're still doing something to strain yourself as you play. A music medicine specialist may be able to help you with the pacing of your recovery. They may also prescribe stretching exercises to help you warm up before you play.
 

Swimming can also be a wonderful aid to violists recovering from injuries. It helps to build muscle tone in the chest, shoulders and back which in turn provides support for the arms. Many people with injuries stop using their arms for anything, and their muscles begin to atrophy. Swimming can reverse that process and help guard against re-injury.
 

Playing injuries are very upsetting to anyone who goes through them. I should know - I hardly played during my whole senior year of college (almost 40 years ago) because of an injury to my left arm. My injury never came back, and I'm convinced that the vast majority of these injuries can be overcome and healed with the help of supportive and innovative teachers and medical professionals. I look forward to your comments.