Throughout the program you'll find terminology that accurately describes certain positions. The common front/back, top/bottom, side/middle descriptions work well enough for someone standing in an anatomically neutral position, but we need terms that are still clear when we change shape.

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We reference particular locations on the body in a three dimensional space. At school you learned to do this using a graph with three axes labelled x, y and z. We won't be measuring distances but we will be moving around in the three planes: xy, yz and xz

The Transverse Plane (xy)

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By dividing the body along the transverse or xy plane we can refer to points closer to the head as superior and those closer to the feet as inferior. When you're standing on your feet like this superior is the same as higher and inferior as lower but if I was standing on my head, or lying on my side, these common terms would not be clear enough.

So in this photo my guitar is superior to my knees and my sandals are inferior to my belt, simple.

The Coronal Plane (yz)

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Standing in the usual position The Coronal, or Frontal Plane, distinguishes between the front and the back of the body. We refer to the region at the front as anterior and behind as posterior.

My guitar here is anterior to my spine which is posterior to my hands.

The Sagittal Plane (xz)

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So the only one left divides the body in half straight down the middle when you're looking front on. This plane enables us to refer to points as being closer or further from the midline. If something is away from the midline we refer to it as bing lateral and if it is closer to the midline we say that it is medial.

In this picture then my right hand is medial to my right elbow while my left shoulder is lateral to my head. Notice too that in this photo I've positioned this smaller auditorium guitar so that my left hand is way too low, this is drawing my shoulder down and my head to the left.

To summarise

• Superior is toward the head and posterior is toward the feet.
• Anterior is toward the ventral side (the front when we're standing) and posterior is toward the dorsal side (the back).
• Lateral is away from the midline and medial is toward the midline.
• Two more that haven't been addressed yet are proximal, which means closer to the torso and distal which means further along the extremeties. They are more useful when referring to the limbs.

Once we know how to accurately refer to the points within the body in a three dimensional space we need to be able to talk about how they get into these positions, how the joints move to change our shape. Again it is important to remove any ambiguity so we refer to these movements as occurring at joints, not limbs. Shoulder flexion is more precise than arm flexion or even upper arm flexion, it tells us where the movement is happening. Rotation is an exception, often referred to as a limb rotating at a particular joint.

Definitions

• Flexion is the movement of the limb in the sagittal plane away from the neutral position. Standing with your arm by your side and raising your entire arm directly in front of you is shoulder flexion. With your shoulder still and your elbow bent it would be elbow flxion. Bringing your knee up behind you is knee flexion. Bending your whole body forward is flexion of the spine. I'm sure you can think of a few more, the defining aspect of flexion is that it happens in the sagittal plane, the one that splits the body left/right.
• Extension is the movement back toward neutral from a flexed position. So bringing the arm back down is extension, straightening the spine again is extension.
• Hyperextension is the continuation of this movement past the neutral position so if you arch your back it is being hyperextended.
• Abduction happens in the frontal plane and refers to a movement away from the midline. Keeping your arm straight and taking it out to your side is abduction. Spreading both arms and legs into a star shape is abduction of the shoulder and the hip joints respectively.
• Adduction (note the 'add') is bringing the limb back in toward the midline. Moving across the midline is also referred to as adduction.
• Rotation refers to movement around a central axis. The spine rotates around it's own axis when we turn to one side or rotate the neck. The arm rotates around an axis roughly in line with the shaft of the humerus during rotation at the shoulder joint.
• Medial rotation refers to the rotation of a limb toward the midline. Your right humerus (upper arm) has to medially rotate at the shoulder to bring your hand into your guitar.
• Lateral rotation refers to rotation away from the midline. Your left humerus rotates laterally at the shoulder when you need to fret high up on the neck.

Of course these movements rarely happen in isolation and in the real world movements are referred to as combinations of the above definitions.
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To reach your right hand around to your guitar the shoulder has to do a few things. Firstly you can see that it is abducted away from the midline. It is also slightly flexed, in front of the body to reach over the width of the guitar. The elbow is also flexed and the upper arm has had to rotate medially at the shoulder to bring the hand down on to the guitar.

There are only four types of human tissue. We cover muscle and nerve tissue elsewhere and epithelial tissue, while being prolific throughout the body, is less relevant to our discussion. Connective tissue however is very relevant.
Function

In order for us to move, or even stand, a number of things have to happen.

• The nervous system triggers an electrical response in muscle tissue to contract.
• Chemical energy is released, and muscle fibres contract with enough force to move and stabilise joint structures.
• This force is transferred to the bone along a continuous matrix of connective tissue. The fascia deep within the muscle extends to the extremity to become tendon and is eventually connected to the supporting fascia of the bone to which it attaches.
• Contraction in opposing muscle groups enable us to move and maintain stable postures

So the fascia has two roles, it connects physically and it facilitates mechanically in the transformation of chemical energy stored in the muscle to the movement of the bone. (It has other functions too they are less relevant to this discussion.)
Structure

Connective tissue is made up, to varying degrees, of fibrous substances called collagen which gives it strength, and elastin which (surprise, surprise) adds elasticity to the tissue, embedded in a matrix of either fluid, solid or gel. The type of matrix and the relative mix of collagen and elastin reflects a phenomenon that exists throughout the body, that is the constant trade-off between strength and flexibility. Tissues rich in collagen tend to be thicker and less flexible but stronger while those with relatively less collagen are more flexible but can't take as much force as they would otherwise.

The structure of thefascia reflects this trade-off. Force is a product of magnitude and direction, the magnitude will determine the thickness of the fascia, that is the density of collagen fibres, while the direction of the force affects the arrangement of the fibres. Broad flat sheets of superficial fascia tend to have fewer collagen fibres that are arranged quite randomly while tendons are thicker and their fibres are mainly parallel, consistent with a more unidirectional force.

Collagen fibres provide tensile strength to the tissue. The forces applied to this tissue determine the density and arrangement of these collagen fibres.
Overuse

Connective tissue responds to the loads placed on it. When a muscle is overused the connective tissue component has more work to do so it lays down more collagen fibres in the direction that the forces are applied. This alignment however depends on the tissue being well hydrated, if it is not the collagen fibres will be laid down more randomly. When they are also densely packed in irregular patterns tendons become thick and inflexible.

Stretching and certain types of massage will encourage both hydration and tension along the line of force of the muscle, encouraging the more regular parallel alignment of collagen fibres required at healthy tendons.

The physiology of tendon injuries is not completely understood but it is now well accepted that both the density and arrangement of collagen fibres is an important factor. Refer to the section on Cumulative Trauma Disorders.

[img_assist|nid=87|title=|desc=|link=none|align=left|width=385|height=181]Myofascia is the soft tissue that generates and applies the force that holds our skeleton in position and moves it around. It is a more accurate term for what is usually referred to as the muscles.

myo - refers to the contractile component, the muscle fibres, the red stuff. These fibres shorten as a muscle contracts, supplying the motive force for the movement, but they are not strong enough to convey that force to other structures.

fascia - refers to the connective tissue component, it gives the muscle its tensile strength. Fascial sheets of varying thickness cover individual muscle fibres, groups of fibres and the muscle itself to eventually converge at either end of the muscle as tendons. These layers of fascia then continue to cover bones, joints and other muscles connecting a series of structures that work together to produce movement.

• The myofibril is the contractile element of the muscle cell, it shortens in response to an electrical stimulus.
• There are many myofibrils in a single fibre (cell) and many fibres in larger groups, called fascicles.
• Muscle fibres, fascicles and the muscle itself are all wrapped in sheets of fascia that converge at the tendons at either end of the muscle.
• These tendons then attach to the fascia that covers bones which in turn is continuous with other myofascial structures.
• The combined forces produced by contraction of the muscle fibres is applied, via these fascial sheets, to the tendon and eventually to a bone to produce movement.

Fascial tension

Fascia doesn't contract and nor does it readily stretch so forces applied to it will create tension. The fascial component of a contracting muscle is said to be under active tension. Because of the way that fascia connects and binds neighbouring structures active tension in one area will be transmitted to other connective tissue and called passive tension.

Contraction of the muscle fibre produces a force which creates tension in the local fascia and in structures with which it shares fascial connections.

There are important ramifications here for guitar players. Tension in one part of the body creates tension elsewhere. When muscles in the shoulder tighten up they pull on fascia that runs down the arm and to the hand. Apart from any postural or biomechanical considerations any passive tension in the arm will restrict movement and eventually change the physiology of tendons and muscles in the arm and hand (refer to the discussion of connective tissue).
Muscle fibres

Different muscles do different things and their fibres vary accordingly. Muscle fibres are essentially pretty simple - they turn on or they turn off. What varies is the speed at which this happens and the energy source that makes it happen.

Cells that contract quickly are called fast twitch fibres and those that contract slowly are called slow twitch fibres.

Cells that need energy fast can get it from glucose which is readily available in the muscle, they are called glycolitic (or white). The payoff is that it runs out relatively quickly so other fibres that can produce energy from oxygen (oxidative, or red), which is a slower more complicated process, then take over.

So the trade-off is between speed and endurance. Postural muscles that have to work a lot of the time have a higher percentage of slow twitch red fibres. Muscles responsible mainly for movement will have higher percentages of fast twitch white and fast twitch red fibres.

Guitarists must ask muscles in the hand and arm, designed for short bursts of energy, to work for longer. They fatigue, produce an excess of chemical waste due to the extra metabolic activity and their connective tissue make up changes. To remain healthy we need to manage this strain that our body is simply not designed for.
Muscle activity

Muscle fibres are specialised cells that have only one function, they contract. Groups of muscle fibres called motor units are each innervated by a single nerve cell whose sole function is to ilicit this contraction. When a nerve impulse reaches the motor unit every muscle fibre within it contracts to it's full capacity, when there is no signal each one lengthens to its resting state. The amount of force produced by a muscle depends on the number of motor units active at any one time.

If enough motor units activate a force will be generated that pulls one bone toward another. If there is no opposing force then the bones will move closer to each other and the muscle will shorten. If however the force of gravity or of another muscle produces a greater force in the opposite direction the muscle will actually lengthen even though individual motor units are generating a contractile force. The word contract is very misleading in this case as the fibres actually lengthen but it's so commonly used that we'll stick with it.

The section on biomechanics explains this in more detail, for now we have enough information to look at some important concepts and define some terms you may see throughout the program.

The nervous and endocrine systems regulate the bodies functions, allowing it to maintain homeostasis, a state of balance. The nervous system is the control centre and can make fast changes while the endocrine system produces and secretes hormones that act more slowly. We are more concerned with the fast acting nervous system.

Nerves transmit electrochemical responses around the body and they do it real fast. The ways that these nerves are connected (here we go again) plays an important role in their function, especially in relation to movement. The connection between nerves in the brain, the spine and the limbs facilitates the transmission of data that controls how we determine our position in space and how we move to change that position. These specific pathways are in the main not predetermined but are developed throughout life. As we learn to catch a ball as a child we are creating neurological patterns that allow us to respond to our environment and move accordingly. We see the ball, we move, we catch it but we have to practice these things. In the practice we are establishing connections in our nervous system that trigger the appropriate sensory receptors and motor units (more about those soon). In the same way when learning to play a guitar we are establishing new connections in the nervous system that allow awkward stiff movements to evolve into automatic fluid ones.

muscle memory
The sensory motor system

Sensory organs perceive changes in our environment, or more accurately our relationship with our environment, and generate an electro-chemical impulse that is passed on to a sensory nerve and eventually to the brain for processing. Some specific types of impulses are intercepted and processed in the spine but they are by far the exception, we'll just say the brain to keep the language as simply as possible.

The brain then processes this input and spits out a signal along a motor nerve pathway that eventually reaches either a muscle or a gland. An action follows that changes our relationship with our environment, the sensory data regulates that change, we adjust motor activity where necessary and eventually reach again a point of equilibrium again.
Proprioception

The vast majority of sensory input is visual so we're used to getting our information this way. The convenient grid shape of the strings on the fretboard and the tendency to play in shapes and boxes within this grid make the guitar a very visual instrument. This tends to make us lazy, too many guitarists play to shapes rather than sounds, never bother to develop really good aural skills and get stuck playing the same old licks all the time because our fingers have memorised these shapes. This is not to mention of course the disastrous impact on our posture that is inevitable when we're looking down at the guitar all the time.

So, as sight-impaired people have learned to do, we need to develop other ways of getting information to our brain. Skeletal muscle is innervated not only by motor nerves but by sensory nerves as well. Proprioceptors gather information about muscle tension and send it north for processing. From this information the brain can determine the relative amounts of contraction and relaxation in various muscle groups and by extension exactly, more or less, where we are in space. When you close your eyes with arms outstretched and bring your finger in to touch your nose you're testing your proprioception.

Of course the only way to develop these skills, to establish the necessary neural pathways, is through practice. There are many technical exercises available for guitar players, those that have been developed for the TuneUp program look very specifically at developing proprioception and muscle memory. With each of them is a more detailed description of how they do it.
Stretching

The nervous system is crucial to our understanding of movement and biomechanics. As the quick-acting regulator it is the nervous system that instigates movement and regulates muscle tone. When you stretch a muscle you're not actually stretching the muscle tissue, you're adjusting the way that the nervous system controls muscle length. Over time this allows the actual fibres to lengthen by a process called creep.

Simple nerve endings in the myofascia called receptors give the brain information with which it can regulate muscle tone and determine your position in space.

Golgi Tendon Organs are located at the junction of the tendon and the main body of the muscle, excess tension here results in a signal to the brain to reduce the signal to the muscle to contract. The active stretching exercises and some of the massage techniques in the remedial program work because they activate the Golgi Tendon organs.

Muscle spindles, or stretch receptors, work the other way. If a muscle is being overstretched it is in danger of tearing and signals from muscle spindles tell the brain to increase tone to maintain the integrity of the muscle. If these receptors are over active they'll be telling the muscles to contract.The sort of physical relaxation that you experience from a good massage and from the exercises in the relaxation program probably works on reducing the activity of these muscle spindles.

Proprioceptors guage the tension in the myofascia. With the information from many different propriceptors you can determine the position in space of parts of your body. You can play without looking at your hands because you've done it enough times that your brain knows that the pattern it's getting from all the proprioceptors represents a certain position.

Connective tissue is ubiquitous, you can't escape it. Fascia in particular weaves its way through the body embedded in muscles and lining bones and internal organs. Sheets of superficial fascia lie just beneath the skin, continuous with the web of deep fascia internal to it. Every time we move, and we're always moving, this fascia is under tension, transmitting forces from one part of the body to another. Here we will examine more closely the sequence of events that gets a sound out of you guitar.

Proprioceptors in your muscles inform your brain exactly where your hands and fingers are. Given that information your motor cortex initiates a firing sequence to take you from your current position to the guitar, let's just look at fretting one note for now. An elctro-chemical signal reaches your arm and generates contraction in the finger flexors and corresponding lengthening of the extensors along with contraction of muscles that stabilise the wrist.

Muscle fibres, each surrounded by a layer of fascia, are arranged roughly parallel with each other so that they all pull in the same direction. The fascial layers typically converge at the tendon at end of each muscle where the combined force of all the contracting muscle fibres is exerted at its attachment to the bone. The bone, itself comprised of connective tissue, is also encased in layers of fascia. The connective tissue from the muscle tendon effectively continues on until it covers the bone. Likewise the fascia surrounding the bone is embedded with the joint capsule providing yet another physical connection, this time to another bone.

So as the finger flexors contract tension is generated in the associated fascia which pulls on the inside of the phalanx (the bone in the finger). Because the extensors have relaxed tension on the opposite side of the finger is reduced and the bone moves around a pivot at the joint until the finger hits the fretboard. At this point touch and pressure sensors tell the brain that now would be a good time to reduce the contraction until there is just enough to keep the finger on the string.

So this simple movement creates tension in the fascia of the hand and the forearm. This fascia remember is not only in the tendons but throughout the muscle, lining the bones and in the joints as well. This isn't a problem when this tension is dissipated through movement but when it isn't, or when the fascia is overused, there will be consequences throughout the musculo-skeletal complex.

Kinematics is the study of human movement

It's analysis examines the types of motions possible at particular joints and the muscles that make them possible. The guitarist needs to move and when he or she can obey the same rules as everyone else we'll be better off.

Biomechanics examines the various mechanical forces that the human body is subject to.

Force is defined by vectors that have both magnitude and direction. If we are examining for example the force required to play a downstroke then we can define a force vector whose direction is down in a straight line and magnitude is dependent on the tension of the string and the attack and volume required from the note.

Occasionally force vectors are more complex and require the combining of a number of component vectors. For example you hit a golf ball and it travels initially in a straight line in the direction that you hit it. Eventually however the force of gravity starts to bring it back down but not in a straight line. The combination of gravity and it's own momentum bring the ball down in an arc. If there is a cross-breeze then we have a third vector in the mix which takes the ball of the fairway all together. Fretting a note culminates in a resultant force directly down onto the fretboard but this apparently simple movement is merely the end result of forces that create tension in the arm, the hand and the finger, each with their own component vector.

The human skeleton is made up of series of levers, the muscles and connective tissue act as pulleys causing the skeleton to move. Each muscle crosses at least one joint with one bone, or lever arm, remaining still and the other moving around the joint in what we call a rotation movement, like the hands of a clock. The linear force produced by the muscle translates into a circular motion at the end of the mobile lever arm. Two types of forces are at play here. Firstly the muscle is pulling the two bones together, producing what we call a compression force at the joint, secondly because of the muscle attaches slightly distal to the joint it also wants to shear the two bones apart in a direction perpendicular to pure compression. The combination of these two forces produces the circular movement.

So while the skeleton moves and the muscles produce the force to make it happen it is the connective tissue that bears the loads. As two bones are being compressed together and sheared apart the connective tissue pulley needs to be strong enough to maintain the stability of the system. For this to happen it is under constant surveillance by the brain, becoming stronger and thicker the more it is used while getting weaker when it is used less in a process called creep. It's thought that when it doesn't have the chance to rest it doesn't self-repair and is subjected to repeated micro-traumas. This is why the term Cumulative Trauma Disorders is more accurate than overuse injuries although both are commonly used.

Understanding Kinematics and Biomechanics will offer the guitarist a number of advantages.

• By reducing mechanical loads we can reduce the amount of force required to move them.
• This will reduce the amount of energy required and therefore metabolic activity and biochemical waste.
• It will reduce the degree of strain on the connective tissue in particular, drastically reducing the likelihood of overuse injury.
• It will allow us to find postures and techniques that allow our hands easier, more fluent access to the instrument.
• It makes it possible to play with a greater degree of relaxation because we aren't working so hard.

The term overuse injuries is descriptive and makes sense to the layperson which is why I've used it in the title. Medically it is an overused one however. Overuse injuries are a specific subset of what are now called Cumulative Trauma Disorders (CTD's), repeated low grade damage to muscle and connective tissue that never gets a chance to heal due to the constant use. Overuse injuries are characterised by repetitive movements where other CTD's are caused by both dynamic and static loading.

The likelihood of injury is greater when the forces involved increase and when the limbs are positioned in other than a neutral position. Biomechanical analysis then of the repetitive movements is vital in the long term resolution of these injuries.

Biomechanical loading is the result of forces produced both externally and internally through the contraction of muscle tissue, and are borne by collagenous connective tissue. They can occur at muscles, ligaments, tendons and bones, structures which all have strong connective tissue components. CTD's that affect the bone, such as shin splints, are uncommon in musicians while most soft tissue injuries tend to show damage to tendon, muscle and ligaments. Nerve tissue is also affected by CTD's.

Tendinopathies

Tendinopathy is the general term used to describe tendon injuries such as tendonitis, tendinosus and tenosynovitis. The muscle tendon is a strong fibrous tissue rich in collagen that conects the rest of the muscle usually to bone but sometimes to other tendons. These injuries used to be thought of as inflammatory conditions, similar to acute strains, but recent research, while not yet finding a solid alternative theory, has well and truly discounted this idea.

It is widely accepted however that problems with the collagen matrix in the connective tissue are related to tendinopathies. Some researches have proposed that it involves series of microscopic tears while others have added that the friction created by the debris from these disruptions causes further damage to the local tissue. The immediate results of cortisone injections with these injuries points to some indication of the collagen matrix and refutes the old infammation theories. It should be added that repeated cortisone injections can make tendons brittle and are ill-advised.

Tenosynovitis is a specific conditions affecting the synovium, a slippery connective tissue coating that helps to lubricate tendons in compact areas such as the wrist and hand.

Muscle injuries

Myofascial trigger points develop over time in hypertonic muscle tissue. The muscle develops localised areas of knotting that are hard, tender and sometimes cause pain elsewhere in the body. They tend to appear in well defined areas and refer pain to equally well defined regions. A common one in musicians is in the upper trapezius just below the ears on top of the shoulder.

Ischaemia is a state in which blood, and therefore oxygen, supply is reduced. It can be caused by damage to or inclusion (blockage) of blood vessels or in areas such as the supraspinatus tendon in the shoulder that are poorly vasculated. Ischaemic muscles tend to be painful when they contract. The pain is thought to be due to an increased build up of metabolites and/or the compression of pain receptors around dry, tight muscle fibres. Proponents of the trigger point theory suggest that long term ischaemia will lead to the development of trigger points. This idea is consistent with what I and most myofascial therapists see in clinic.

Muscle strain occurs when muscle fibres are torn, either in an acute unjury or over time. Muscle tears in CTD's are smaller, usually microscopic but still result in weakness, pain and and can lead to more serious problems such as those just described. Muscle strain due to postural loading is very common amongst musicians and guitarists are not immune to it. The many and varied postural approaches we tend to take, usually ruled by habit more than technique, tend to significantly exacerbate the problem.

Cramp is caused by contraction of shortened muscle and best relieved by stretching. It is exacerbated when muscles are fatigued and inflexible, dehydration and heat are also factors. Cramping in the left hand and forearm is common when we conitnue to play after the arm becomes fatigued. There are mountains of information in the program that deals with the causes of fatigue, inflexibilty and what to do about them.

Apart from these purely medical definitions the main problem is a general lack of conditioning brought on by the 21st century lifestyle. Our bodies have evolved to be hunters and gatherers, we're supposed to run for days, throw spears and wrestle tigers and most of us don't. We develop areas of weakness, tightness, some muscles are too short and others are too long and then we sit down for four hours hunched around a guitar, a bit silly really.
Ligament injuries

Most ligament injuries are relatively rare in musicians and tend to accompany tendon injuries, in which the treatment principles are the same: rest, reconditioning and rehabilitation of the offending activity.

Nerve injuries

Nerve injuries are not much fun, they tend to develop over time as with long term muscle hypertonicity either compressing nerves directly or causing postural changes that then result in compression by bony structures. Thoracic Outlet Syndrome is a condition that effects the nerves coming into the arm and is caused by compression between the scalene muscles in the neck and the first rib. Compression of the median nerve in the wrist will cause carpal tunnel syndrome. Radial, median and ulnar nerve entrapment are also caused by compression of muscles in the arm and a potential problem for musicians. If you suspect you may have one of these conditions get it checked out. The program will help with your rehabilitation but you need treatment.

What we know about CTD's

So while there are still lots of things that we don't know about Cumulative Trauma Disorders, and Overuse Injuries in particular, there are a few things that we do know.

• The likelihood of injury is greater when the forces involved increase and when the limbs are positioned in other than a neutral position.
• Muscles will shorten permanently when they are maintained in a short position for a length of time and to lengthen permanently when not being used over time in a phenomenon called creep.
• Tissues generally, muscle tissue, connective tissue and nerve tissue, suffer from hypertrophy from excessive use and atrophy from inadequate use.

Risk factors?

• Inadequate physical conditioning causes the sort of myofascial imbalances that are endemic in modern societies.
• Playing with excessive tension from stress, poor technique, postural imbalance, or simply not warming up will damage you body.
• Inadequate rehabilitation from previous injuries will compound new damage on top of old.

Treatment

Rest, Reconditioning and Rehabilitation of problematic activites.

The back and neck can become strained from either sitting or standing for long periods. The main problem with the back is that it's not strong enough to hold us up. Small muscles close to the vertebrae become loaded as the spine loses it's natural curves and both large sections of the spine and individual segments lose their mobility. Eventually muscles hypertrophy and become ischaemic, spinal nerves can be impinged as spinal segments lock or when intervertabral discs move and compress them against bony structures.

Our spine doesn't cope too well with sitting on chairs, it's just not designed to do it well yet we spend most of our time on them. It's important that we learn to sit properly when we're playing, regardless of the position we prefer. A good section of the program is devoted to relearning how to sit.

The tendency to look down at our guitars causes much of our problems and is particularly bad for the neck, loading muscles at the back of the neck that can contribute to neck pain and tension headache. Again we need to learn to sit properly. When standing this tendency also makes us push our instrument forward, loading the low back as it arches. Strategies in the members section reduce tension in the legs and lumbopelvic areas taking the strain off your lower back and helping you stand correctly.

Occasionally neck and back pain can indicate a more serious pathology, if they persist or significantly restrict your movement you need to seek medical attention.

Cumulative stress disorders of the neck and back

Movement of the spine is controlled by muscles that span individual vertebrae and those that control larger sections of the spine. The smaller muscles that cross from one vertebrae to another immediately adjacent, while being active during movement, cannot compete with the larger back muscles and functionally there main role is to stabilise individual vertebral units, in a similar way to the spinal ligaments. The larger muscles will be discussed here.

The muscles of the back

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Because of the central role of the spine and it's connection to other skeletal structures, not all muscles that move the spine are connected to it. The rectus abdominal muscle for example runs from the pubic bone at the front of the pelvis up onto the ribs but is the main muscle responsible for flexing the trunk. When you're crouching over your guitar it pulls the ribs down toward the pelvis the spine has only one way to go. A number of other muscles in the back also control the movement of the spine

The parvertebral muscles

Also called the erector spinae group, even occasionally by their individual names, these muscles attach to the spine and span a number of vertebral units. They all do essentially the same thing and are only distinguishable by their individual attachments, some control just the lower back, others the thoracic, others the neck. Their fibres run upward obliquely from lateral to medial and control flexion, rotation and extension of the spine. The large rows of muscles that you can palpate either side of your spine are the paravertebrals.

Quadratus Lumborum

This muscle doesn't attach to the spine itself but runs from the posterior crest of the pelvis up onto the last rib. It tends to fatigue when you've been standing for too long, especially if your pushing your pelvis forward when upper body weight is directed more posteriorly and when standing on one leg the QL on the other side has to work to stabilise the position of the pelvis. It's main function is to bend the back to one side or, when they both act together, to extend the lower back.

The Abdominal Obliques

There are two abdominal oblique muscles, named for the direction of their fibres. The external oblique originates at the linea alba a vertical connective tissue cord in the middle of the abdomen and runs upward laterally to wrap around and attach onto the rib cage. The internal oblique originates on the anterior pelvis and the fascia of the lower back and runs up onto the line alba. This arrangement makes the fibres of the external and internal oblique muscles cross each other and also means that as they cross the centre line one muscle appears to continue on to the other.

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Kinematics

The spine has 3 degrees of movement, it can rotate around its own axis, it can bend laterally and it can bend forward and back. This movement occurs across a range of smaller functional units under the influence of the muscles described in the previous page.

These smaller units consist of two vertebrae, relevant ligaments and muscles and the intervertebral disc. Movement at these smaller units is side to side, front to back and a rotation around a central axis. These movements depend on facet joints between the vertebrae as described in the anatomy section.

Biomechanics

Two types of forces are at play at spinal joints, compression forces and shear forces, refer to the section on biomechanics for a fuller explanation of these cocepts, they become quite clear in the examples that follow.

The force of gravity acts on the upper body mass above any particular vertebrae to create a downward force on it. A corresponding stabilising force from below pushes up creating a compression that is absorbed mainly by the intervertebral disc. When you're standing upright a force of around 1,000N compresses the intervertebral disc at L3/L4, in the middle of you lumbar spine. Add your guitar to you upper body weight and the force increases proportionately.

Any change in position will also increase the amount of force acting on any given vertebrae. At L3/L4 the compressive force will increase approximately 270% during both flexion and extension of the spine. The two examples to follow outline common practices of leaning over a guitar both sitting and standing that involve significant amounts of flexion and extension in the lumbar spine.

Sitting

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This is a common sitting position that is highly problematic, we'll focus for now on the lower back. With so much of the downward force originating in front of it's eventual destination in the lumbar spine, it's eventual direction component is both inferior (down) and posterior (toward the back) as represented by the larger black line pointing down at an angle tries to dislocate the spine by pushing back and slightly down (the smaller black line). This force is not strong enough to break your spine but it will push you off your chair unless it is resisted by muscles and ligaments in the lower back.

Sitting on a flat surface on the back of your ileum will rotate the pelvis posteriorly. The lumbar spine then has only one way to go as it rises from the pelvis and this trajectory totally eliminates the familiar spinal shape in favour of the single curve that we had as infants. When you sat like this at school you had to pull your head back to look up straight ahead. This tends to happen high up in the neck as the lumbar curve continues through the thoracic and only heads north at the last opportunity. When looking down however the whole spine adopts this curve, there tends to be a further increase in the forward bending of the thoracic and, as you'll see in the second module, a subsequent mal-orientation of the scapula.

Standing

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Standing with a guitar presents the spine with another set of biomechanical challenges. This time the upward resisting force has to come from the legs and pelvis. When the core postural muscles, the abdominal and particularly the iliopsoas are weak the pelvis will drift forward and over time the hamstrings and hip rotators shorten due to the extra load. This shape tends to transfer the weight of the upper body from the legs and the other core postural muscles to the lower back. In an effort to reduce the shear forces on the lumbar spine the upper back bends back and then forward so that the combined downward force is more or less straight down. This may reduce shear forces but the hyperextension of the lumbar spine and the weight of the guitar significantly increases the compressions forces on not only the lumbar vertebrae and the intervertebral disc but the posterior ligaments and paravertebral muscles as well. The extension of the lower spine in this position also calls the quadratus lumborum into play as it is a spinal extensor, causing it to fatigue.

The angle of the lower back in this position needs to be compensated for further up the spine. If its normal shape continued upward from here we'd end up looking at the ceiling all of the time. Even to look straight ahead from here requires us to bend the upper body forward. The guitarist adds, as well as the extra weight of the instrument, a few more complications to the mix. In order to see the guitar the pelvis pushes it forward, adding to the hyperextension in the low back, and the upper spine flexes forward to bring the head down.

Muscles at the back of my neck are working overtime to keep my head in this position. They are supposed to stabilise and maneuver the neck and shoulders, this much weight bearing will be simply too much for them.

[img_assist|nid=43|title=|desc=|link=none|align=left|width=300|height=510]Your spine is a masterpiece of engineering. It consists of 33 vertebrae, 5 of which are fused at the sacrum and 4 are fused at the coccyx while the remaining 24 are free to articulate with each other, the ribs, the sacrum and the skull to create a structure that elegantly combines mobility and stability.

It is supported by muscle and connective tissue. Close to the spine a layer of ligaments connect individual vertebrae and the entire spinal column at both the front and the back of the spine. Smaller muscles close to the spine connect adjacent vertebrae while the larger, more superficial ones span sections of the spine.

At adjacent vertebrae four intervertebral, or facet, joints open and close to facilitate relatively small movements, the combination of which results in the overall movement of the spine.

The spine contains and protects the spinal cord, the part of the central nervous system that links to the rest of the body. This important function defines much of it's biomechanics as the vital role of maintaining the integrity of the nervous system must take precedence over the need for mobility.

The vertebrae

Vertebrae vary depending on their location but most of them share the same basic structure. Anteriorly the vertebral body is the weight bearing structure so it is larger in lumbar region and smaller higher up in the neck. Intervertebral discs lie in between these vertebral bodies to cushion the forces between them. Posteriorly the spinous process and two transverse processes provide connection sites for muscles. The empty space in the middle makes up a section of the spinal canal.

Small bony projections called facets sit above and below the vertebrae. The shape of the superior facet complements that of the inferior facet in the above vertebrae so that they fit against each other at a facet joint. Four of these joints above each vertebrae and four below open and close as individual vertebrae move. These small movements occur up and down the spine and accumulate into the larger movements of the spine itself.

These movements are of course orchestrated by the myofascia and it's master the nervous system. Small muscles connect adjacent verterbrae and control the movements at individual facets. Larger muscles that move the spine as a whole also affect these facet joints because this is the only way that the spine can move. In these movements however lots of joints open and close so there is room for compensation when some don't want to play the game.

Facets meet each other at particular angles that determine both the direction and the degree of movement that is possible at each one. Occasionally, for a variety of reasons, some of these facet joints will be locked, either open or closed, and the vertebrae won't move in a certain direction, this is often referred to as joint subluxation. If posterior facet joints are locked closed the superior vertebrae will be displaced slightly posteriorly and not able to bend forward, this is common when the upper back stiffens up to compensate for an excessive lumbar curve or sway back.

These sort of local joint dysfunctions co-exist with the myofascial imbalances associated with more general postural dysfunction. Whether the locked joint causes the stiff back or the myofascial loading overloads the joint is a matter of debate amongst folks who like to debate such things. In the real world they exist together and both need to be resolved. It is entirely possible for us to address myofascial loading with exercise, stretching and changes to technique. Depending on the degree of subluxation you'll more than likely need someone to help. If unsure ask your doctor, generally osteopaths and chiropractors treat joint dysfunction, some physical therapists are also licenced to do this but you need to check, the regulations are different across jurisdictions.

[img_assist|nid=12|title=pectoral girdle - anterior view|desc=|link=none|align=left|width=432|height=242]The two bones of the pectoral girdle, the clavicle and the scapula connect the upper limb with the rest of the skeleton. The clavicle attaches to the sternum at the sternoclavicular (SC) joint and the scapula connects with the arm at the glenohumeral (shoulder) joint, they connect with each other at the acromioclavicular (AC) joint.

The clavicle

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The clavicle is a thin irregular shaped bone that provides the only contact of the arm with the rest of the body (at the SC joint). It acts like a strut keeping the scapula, and therefore the shoulder, in position away from the rest of the skeleton.

The scapula

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The scapula as a larger irregular shaped bone that provides a stable base for the arm to move on. It is most easily viewed from behind. It consists of a flat triangular plate with a bony ridge (the scapula spine) running transversely across it’s posterior aspect from about two thirds up on the medial border to the lateral corner. At the extremity of the scapula spine the acromion process connects with the scapula at the AC joint. The glenoid fossa of the scapula is a large concavity on the antero-lateral aspect (on the side to the front) that holds the head of the humerus (at the shoulder joint).

The shoulder positions the hand in space and demonstrates a wider and more varied range of movements than any other structure. Movement at three joints and a mobile base in the scapula allows the arm to move through it's full range.

The clavicle moves forward and backward, up and down, and rotates on it's own axis. Rotation accommodates scapula movement at the outer ranges of abduction while the larger movements position the shoulder at the lateral end of the pectoral girdle.

• Place your left hand on your right clavicle, the bone running laterally from the base of the neck to the shoulder.
• Move your shoulder back and forward, up and down and notice how the clavicle dictates the position your shoulder.
• Lift your arm out to your side as far as it will go, the clavicle will rotate posteriorly.

The two pectoral muscles pull the shoulder forward while the rhomboids and middle trapezius pull it back, the upper trapezius and levator scapula muscles lift the shoulder and the lower trapezius, and gravity, pull it back down. Lifting your arm to the side is done initially by supraspinatus, then the larger deltoid and then through a series of events that rotate the scapula laterally.

The muscles of the shoulder

trapezius The large external muscle that acts on the upper back, neck and shoulders.
serratus anterior Connects the scapula and the rib cage and an important muscle in positioning the scapula
levator scapulae Deep to trapezius, levator scapulae is often involved in neck and shoulder problems.
pectoralis major The large muscle that covers most of your chest
pectoralis minor A deeper muscle in the upper chest that tends to pull the shoulder forward and down.
the deep flexors Similar functionally to pec minor these ones attach on to the arm.
the medial rotators Along with pec minor and the deep flexors, these will pull your shoulders in, closing off your chest
the lateral rotators At the back of the shoulder these ones rotate the arm the laterally
supraspinatus Connects the scapula and the humerus and is highly susceptible to overuse injuries.
deltoid The large muscle that covers the shoulder, also has a lot of work to do.
rhomboids Connecting the scapula to the spine they fatigue easily and can cause pain in the upper back.

The two shoulders have to hold the arms in different positions and are subject to very different loads.

The right shoulder

The muscles in the shoulder, more than anywhere else, have a dual role of creating movement and keeping the structure stable. If a muscle attached to the scapula wants to move the arm then the scapula needs to stay still. Because it's only skeletal attachment to the rest of the body is through it's connection with the clavicle the muscles of the pectoral girdle must adjust to maintain the position of the scapula as the forces moving the arm are also acting on it.

Look at a room full of guitar players, they all look the same, hunched over their instruments with their right shoulders reaching forward to the strings and scapula almost horizontal.

This movement of the scapula takes place relative to the posterior thoracic wall, the back of the rib cage. As the scapula elevates (upper traps and levator scapulae) it rolls forward on the curve of the rib cage so that it also tilts forward. As it moves laterally (serratus anterior) it rolls around toward the side so that the glenoid fossa is facing the front. These two movements, tilting and winging respectively, occur at the AC joint as the scapula articulates with the clavicle. They are common, and to a degree necessary, as the right arm reaches forward with medial rotation to attack the strings but are all too often exaggerated and cause problems with the shoulder and from there with the rest of the arm.

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In the illustration on the far left you can see how the scapula can not possibly lift straight up, it would have to come away from the thoracic wall. Instead it rolls forward a little as in the the second illustration. If however we lean forward it has to roll even further. This effectively adds up to 30˚ of medial rotation to the humerus, pushing the arm into the guitar.

• Sit up straight with your hand on your lower abdomen about the same height that it would be if you were playing your guitar
• Bend your upper back forward as if you were bending over your guitar. Feel the extra pressure you're using to push into your body and how the shoulder has to lift to accommodate it.

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The right shoulder has to position the arm to take the hand to the strings. To do this it must, to varying degrees depending on the size of the guitar and the length of the arm abduct, medially rotate and flex. This places the scapula in an elevated, abducted position, importantly also the degree of winging and tipping is significantly exaggerated. Detailed explanations of these positions in relation to the scapula can be found at the explanation of the acromioclavicular joint (coming soon).

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The position of the scapula needs to be maintained by the rhomboid, serratus anterior and upper trapezius muscles posteriorly and pectoralis minor and the deep shoulder flexors anteriorly.
The excessive winging of the scapula that is generally a part of reaching forward to the strings seperates the medial border of the scapula from the rib cage and, combined with scapula abduction, puts a lot of strain on the serratus anterior muscle. Overuse of serratus anterior will eventually cause pain around the bottom and inside of the scapula.

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The scapula follows the contour of the rib cage as it finds it's position. When the thoracic curve is increased, such as when we lean forward, the winging and particularly the tipping of the scapula is exaggerated. As well as increasing the risk of injuring the strained shoulder muscles this position tends to pull the forearm into the body of the guitar making it more difficult to keep your hand away from the bridge as you pick.

The left shoulder

The left shoulder presents less of a problem than the right. With the shoulder relaxed and the guitar in the right position the left arm simply needs to hang vertically from the shoulder joint.

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The arm is held in a neutral position by the superior ligaments of the glenohumeral joint and passive tension in the tendon of the supraspinatus muscle, pulling the humeral head medially into the glenoid fossa.

The weight of the arm alone probably doesn't rely on an active suprapsinatus but when the arm is loaded in this position, for example when you carry a guitar in its case, the muscle contracts to protect the joint capsule and help pull the humerus into the scapula.

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Most of the time the left shoulder should support the arm in a neutral position, that is hanging loosely by the side with the elbow resting tucked in to the waist. Movement of the hand up and down the fretboard should be accomplished with shoulder rotation and minimal adduction/abduction.

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The position of the scapula determines the position of the upper arm and therefore the hand. The more that your left shoulder varies from this neutral position the more difficult it will be to place your hand efficiently at the fretboard. Conversely where you put your hand will effect the shoulder.

The most common problems with the left shoulder relate to hand positioning. In the photo on the left my guitar is angled up so that I can look down at it forcing me to flex my wrist more than I should have to. Apart from what this does to my wrist and hand it also moves my elbow forward which I can only do by extending my shoulder and depressing my scapula, probably in combination with lateral deviation of the thoracic spine. This requires sustained contraction of at least the anterior deltoid, lattisimus dorsi and lower trapezius as well as all of the compensatory stabilisation that is inherent in shoulder biomechanics.

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Elevation of the scapula, either holding a strap on or positioning the hand, is another one to watch, it significantly restricts the freedom of humeral rotation and will strain the trapezius and levator scapulae muscles causing shoulder and neck pain.

The shoulder elevators often respond to stress by shortening, bringing your shoulders up toward your ears. Any elevation of the shoulder will cause the elbow to wing out to the side and bring the thumb over the neck.

The shoulder is prone to muscle strain, particularly of the rotator cuff (especially supraspinatus), serratus anterior and upper trapezius muscles. The position of the right shoulder is a problematic one for guitar players as is the myofascial tension usually present on both sides. Many technical difficulties with the position of the hands can be traced to shoulder tension which again has a significant impact on the fluency of our playing. Refer to the section on shoulder biomechanics.

Cumulative Trauma Disorders of the shoulder

Biomechanically the elbow is relatively straightforward since it has only this one simple motion. Two other joints however can be considered as part of the elbow complex. The two bones in the forearm run parallel to each other when the palm is face up and they cross when the palm is face down. They articulate with each other at either end at the proximal and distal radioulnar joints. Although the distal radioulnar joint is closer to the wrist it is considered part of the elbow complex becauseof its close functional relationship.

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At the proximal radioulnar joint, near the elbow, the relatively small head of the radius fits into the radial notch of the ulna, a small concavity on its lateral side. Attached to either side of the radial notch the annular ligament encircles the radial head like a ring keeping it in place and allowing it to swivel as the radius crosses the ulna.

At the other end of these bones near the wrist is the distal radioulnar joint. This time the ulna is relatively smaller and it's head fits into the ulnar notch of the radius. A structure called the articulating disk connects the two bones and seperates them from the wrist.
Because most of the muscles that control the wrist and hand originate at the elbow the great majority of elbow conditions can be traced to their overuse. The description of the biomechanics of the wrist and hand explains how these muscles are used.

Muscles that articulate the elbow joint

Bicep brachii crosses the elbow joint to insert proximaly on the radius and the deep fascia of the forearm. It and the brachialis muscle, which inserts proximaly on the ulna are powerful flexors of the elbow. Brachioradialis originates lower on the humerus and also crosses the elbow but attaches closer to the wrist on the distal radius. This orientation means that as brachioradialis contracts it's force contributes more to compression of the elbow joint than it does to movement. Posteriorly the elbow is traversed by the tricep brachii, a powerful extensor.

Elbow pain is generally due to muscles that insert on either side of the elbow and cross the wrist acting on the hand and fingers. Because they're less relevant biomechanically to the elbow they are discussed in the section on wrist. Of course there's an exception, the pronator teres muscle is implicated along with the wrist extensors in lateral epicondylitis.

The degree of elbow flexion depends on the size and position of the guitar. If you're sitting the left elbow will flex more than 90˚and the right will be close to 90˚. The degree of flexion varies more when you're standing depending on how low you carry your guitar.

Left arm

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With the left arm hanging from the shoulder and the elbow tucked in to your side there is between 110˚ and around 40˚ of elbow flexion and no pronation. This is a relatively simple job for the elbow and a good one to demonstrate the basic forces at work in any static posture. The agonist muscles in this position are the brachialis and biceps brachii. There insertions high up on the forearm make them suitable for producing large movements of the distal limb such as this one. The brachioradialis muscle produces a force that compresses the joint, pulling the distal end of the radius in a straight line toward the humerus. The tricep brachii is the antagonist having to lengthen to allow the elbow to flex. Tricep also acts as a synergist muscle with a low level isometric contraction contributing to the stability of the elbow joint.

Right arm

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The right arm is flexed anywhere from 120˚ to close to straight depending on the size and position of the guitar. The description of elbow flexion for the left arm is just as applicable here. The different position does however alter how some of the muscles are used.
The slight flexion of the shoulder increases the load on the tricep, it's long head being subject to some passive tension, but this should only be a factor if it was already limiting elbow flexion.
There is some pronation of the right forearm which can contribute to strain at the medial epicondyle. Its orientation almost parallel to the ground means the the radial deviators are working against gravity. Overuse of one of these: flexor carpi radialis, is also a factor in medial epicondylitis.

Elbow pain is generally related to tendinopathies in the muscles that control the wrist and hand. On the inside (ventral surface) of your arm the wrist and hand flexors originate on the medial epicondyle. On the outside, the dorsal surface, the extensors of the wrist and hand attach on the lateral epicondyle.

Cumulative Trauma Disorders of the elbow

[img_assist|nid=14|title=|desc=|link=none|align=left|width=300|height=356]The wrist is comprised of two rows of small irregular shaped bones called carpals that articulate with each other as if they were two individual units. The proximal row also articulates with the forearm (the radius and the radioulnar disk) at the radiocarpal joint while the distal row articulates with long bones in the hand (the metacarpals). Within each of the rows much smaller movements can occur between individual carpals.

The range of motion at the wrist is limited by the shape of these articulating bones. They don't fit together too well. Flexion and extension of the wrist require the two rows slide across each other, eventually locking up due to tension in the connecting ligaments and the individual bones contacting each other.

Flexion of the wrist involves bringing the palm toward the inside of the forearm, like when your fingerpicking. The maximum range is about 85˚. The opposite movement, extension has a range of between 70˚ and 80˚. It can also move from side to side, radial deviation, or movement to the side the thumb is on is about 20˚ to 25˚while ulnar deviation is between 30˚ and 35˚.

The main function of the wrist is to adjust the tension in the muscles that control the hand and fingers. Because they cross the wrist their length and therefore the passive tension in the connective tissue will change as the wrist moves.

Muscles that articulate the wrist

The muscles that articulate the wrist can be broadly grouped according to their action. The flexors originate on the medial epicondyle of the humerus, traverse the inside of the forearm and connect on the carpals of the wrist, the metacarpals of the hand or the phalanges of the fingers and thumb. The extensors originate on the lateral epicondyle of the humerus, run down the back of the forearm and again attach on the carpals, metacarpals or phalanges.

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So while the flexors flex and the extensors extend these aren't the only movements available at the wrist. Lateral deviation toward the ulna (the little finger) is possible when both flexor and extensor on the ulnar side (flexor carpi ulnaris and extensor carpi ulnaris) contract together. Lateral deviation toward the radius involves both flexor and extensor on the radial side although extensor carpi radialis muscles do most of the work. Two muscles that control the thumb: abductor pollicis longus and extensor pollicis brevis are also active in radial deviation of the wrist but to a lesser degree.

The wrist muscles also act to stabilise the wrist when the hand is moving or grasping objects. Because the finger flexors for example cross the wrist their contraction should cause the wrist to flex as well. The reason that this doesn't automatically happen is that wrist extensors produce a force in the opposite direction cancelling out any movement of the wrist. This has implications for our playing given the amount of movement that the fingers have to do.

Apart from contributing to the position of the hand the primary function of the wrist that has relevance for us is its role in adjusting the tension in the extrinsic muscles of the hand. The wrist flexors and extensors described previously insert onto the carpal bones, parallel to these the extrinsic hand muscles cross the wrist and continue onto the fingers.

Holding your wrist in a fixed position, say fully flexed, will cause the finger flexors to shorten and the extensors to lengthen. Having to work from this position causes a few problems. The flexors are already shortened because of the position of the wrist so asking them to shorten further uses more energy than it would otherwise (a phenomenon called active insufficiency) causing muscles to fatigue and eventually cramp.

Exercise

• Holding your wrist straight make a fist with your hand, shouldn't be a problem.
• Now flex your wrist and try to do the same thing.

Common wrist positions

It is not difficult to achieve a neutral wrist position on either side once the basic posture and shoulder positions are sorted. Having said that there are a number of common presentations that will always increase tension in the hand.

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If you tilt your guitar back to see the fretboard you're forced to reach around like this with your left hand. This shortens the flexors of the wrist and the fingers and adds considerably to the tension in the arm and hand.

If you're standing and have the guitar low on a long strap you'll also have to do this when playing barre chords. This will be a real problem if you're a rhythm player in a rock band.

[img_assist|nid=29|title=Extension of the left wrist|desc=|link=none|align=left|width=280|height=204]

This thumb position will cause wrist extension when the guitar is high on a strap or if you're sitting. This position creates significant passive tension (stretch) in the muscles that abduct and extend the thumb (blue line) and active tension in the finger extensors (red line).

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This position is more problematic for acoustic players, increasing tension in the dorsal forearm extensors. The front of the wrist looks straight here but as you can see the back of the hand is pulled up away from the wrist in an extended position. Muscles that attach here have to shorten to maintain this position. It's the same dynamic as when you hold a mouse (your computers mouse) or use a trackpad incorrectly.

It's less of a problem for electric players, the thinner body and the lower positioning allow for a more neutral wrist.

[img_assist|nid=21|title=|desc=|link=none|align=left|width=372|height=265]The fingers comprise of three long bones called phalanges while the thumb has just two. Each of the four fingers and the thumb attach to a corresponding metacarpal, long bones that form the body of the hand.

The joints where these bones articulate are named according to these bones. So we have metacarpophalangeal joints between the metacarpals and phalanges and interphalangeal joints, distal and proximal, between the phalanges. The five metacarpals connect with the wrist at the carpometacarpal joints.

Apart from the thumb, which has a wide range of motion, flexion and extension is the main movement of all of the joints in the hand. The range of flexion increases from radius to ulna so the little finger has more than the first.

The fingers are also able to adduct and abduct, allowing us to spread the fingers. It occurs mainly at the metacarpophalangeal joints (so the fingers move but the metacarpals don't) although the metacarpal of the little finger is also capable of lateral movement. When the wrist or fingers are flexed this lateral movement is restricted.

Muscles that articulate the hand

Two groups of muscles articulate the hand. Muscles that originate on the arm and cross the wrist are called extrinsic muscles while those that originate on the hand itself are called intrinsic muscles.

Extrinsic muscles of the hand.

It's not as complicated as it may look.

• Flexors are on the inside of the forearm and extensors are on the back.
• The larger extrinsic muscles branch in the hand to connect to all four fingers. Individual fibres within the muscle control particular fingers.
• Two muscles flex the fingers. A deep one connects to the end of each finger, it does most of the work and acts on the whole finger. A more superficial one connects to the base of each finger and helps out when the wrist is flexed or when you don't need to flex the whole finger.
• Only one extrinsic muscle flexes the thumb
• There is only one main muscle that extends the fingers, it attaches on the middle bone of the finger and to the end of the finger via a mechanism of tendons. Two other extensors attach to the index and little fingers giving them greater independence.
• Three muscles extend the thumb at different points, one of them is also an abductor.

Intrinsic muscles of the hand

The interossei lie on either side of the hand between the metacarpals and the lumbricals are on the palmar side between the deep flexor tendons of the fingers. Their primary function is in adduction/abduction of the fingers and to contribute to fine motor control.

• Adduction and abduction of the fingers. Positioned between the metacarpals they attach onto the proximal phalanges enabling them to spread the fingers.
• Assisting in flexion and extension of the fingers. Because they lie in between the metacarpals the position of the fingers, as determined by the extrinsic muscles will sometimes put them closer to the front (making them flexors) and sometimes closer to the back of the hand (making them extensors).
• Acting as synergists to control the finer positioning of the fingers. For example your fretting hand is sometimes extended at the first knuckle (metacarpophalangeal joint) while the fingers themselves are flexed. In this position the larger extrinsic flexors and extensors compete with each other, passive tension in the interossei helps you do this with a greater degree of control.

The other intrinsic hand muscles control the thumb and the little finger, allowing the hand to close in and grip objects. Look at your hand and you'll see two fleshy pads at the base of the palm. On the thumb side (the thenar eminence) are the three thumb muscles, there are three more on the ulnar side controlling the little finger and one in
the middle.

The following descriptions are meant to explain the biomechanics of the hand, not to infer a preference for one style or technique over another. Any suggestions are purely in the context of reducing the tension in the hand, if you can live with a certain amount of tension, and we all can, then whatever works for you is great. If it's not working however......

The left hand

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Opposition of the thumb is required to place it behind the neck of the guitar. It is accomplished by abductor pollicis longus (see De Quervains tenosynovitis), palmaris brevis and the three muscles on the thenar eminence. In combination they flex, adduct and medially rotate the thumb, bringing it to the hand, or in our case to the back of the guitar.

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Placing the fingers on and off the strings is accomplished by the flexors and extensors and moderated by the intrinsic hand muscles. In the example here the flexors (red line) are contracting to pull the finger down on to the fret. The extensors (blue line) have to stretch to allow this to happen. When you extend your finger to take it off the fretboard the opposite happens.

As we've seen with our discussion of the wrist the extrinsic hand muscles will have to work overtime when the wrist is not in a neutral position. This in turn adds to the load of the smaller intrinsic muscles causing fatigue and cramp.

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Flexion of the metacarpo-phalangeal joint (the large knuckle at the base of the finger) brings the fingers in toward the hand, or in our case to the fretboard. It also increases the force needed by the interossei to abduct (seperate) the fingers. Again this extra energy requirement will lead to fatigue in the hand and eventually cramping.

The right hand

Fingerpickers obviously face different challenges to flatpickers. Everyone though, particularly for right hand technique, needs to have soft relaxed hands, we know this already. Just focusing on relaxing your hands is not enough though. They need to be in a comfortable position and for this to happen your whole body needs to be relaxed, your shoulders should be soft and in the right position to get the arm at a good angle to approach the guitar properly.

Then there's the problem of knowing how to relax in the first place, if it were that easy we'd all be doing it. This is why the relaxation techniques in the program are graded, it's the best way to learn what is for some, a challenging task.

Flatpicking

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Holding the flatpick between the thumb and first finger requires opposition of the thumb and flexion of the first finger, providing you don't hold it too tightly this should be a comfortable position and not cause any problems. Picking the strings requires, to various degrees, lateral deviation, supination and pronation of the wrist and flexion and extension of both the first finger and the thumb. Strumming chords will also involve flexion and extension of the elbow if you are leaning over a thin guitar close to your body, but more often rotation of a flexed shoulder.
Resting the wrist on the bridge creates tension in the extensors of the dorsal forearm as well as restricting access to the strings. Your hand will relax considerably more once you get it off the guitar completely.

Fingerpicking

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Fingerpickers need to deviate their wrist to the ulna side in order to orient the knuckles parallel with the strings. The movement of the fingers is not dissimilar to the left hand although there shouldn't be any abduction and less force is required because we're not pushing into the fretboard.

The same principles apply as here as they did for the left hand, in order for the intrinsic hand muscles to work best the larger ones need to be relaxed. A gentle curve rather than a claw in the right hand will reduce the tension in the extrinsic flexors and therefore the intrinsic muscles as well. I'm positioned for pattern picking here so my index finger is up on the G string which makes it claw more than it would if I was playing melodic lines more like a classical player.

To avoid wrist flexion the thumb picks the bottom strings by adducting and abducting up and down roughly parallel to the strings, depending on the guitar.

For most guitarists the main problem with the hand will be fatigue and the inevitable cramping that follows when we play through it. The left hand tends to suffer more because pressing onto the fretboard requires more work from the muscle.

The main causes are related to technique, excess tension in the hand and simply playing too much. The most immediate problem is that your playing is severely restricted, there is no way you can play your instrument fluently if there is excess myofascial tension in your hand, arm or shoulder.

Tension, or hypertrophy, in the muscles of the wrist and hand can, over time, lead to more serious medical conditions. I've listed a few of them below that are typical of Occupational Overuse Syndromes affecting the hand and wrist along with their Wikipedia links. Check out the links page and our friend Google for more information on them. Keep in touch here as well I'm always looking at the latest research and I'll keep you posted.

Cumulative Trauma Disorders of the wrist and hand

The change from the classical position has brought the guitar more to the right and while it’s not good for the right shoulder it is better for the left side. The main problem that people face here is the tendency to lift the shoulder. This is totally avoidable and easily managed.

	Left shoulder elevated. Elevation of the lefts shoulder will accompany elbow winging and this thumb position		Left shoulder elevated. Even with the shoulder relaxed it can't be avoided.
	Left shoulder elevated. - lateral view. The same position from the side.		Standing position with the guitar held lower. Holding the guitar lower is another way to relax the left shoulder if you need to keep your thumb in this position.
	The standard classical position. No elevation as long as we rely on shoulder rotation to reach the top of the neck		Left shoulder depressed. With the guitar a little lower the shoulder has to drop to get the hand behind the neck
	Left shoulder extended. Any sway in the back caused by pushing the pelvis forward will add to scapula tipping and shoulder extension

As you’ll have seen from the biomechanical analysis if the left elbow is tucked into your side, hanging vertically from your shoulder, then your shoulder is doing it’s job. In order to achieve this and to encourage maximum relaxation all the way down the arm it needs to be as relaxed and in as neutral a position as possible. The strategies that we applied to the right shoulder are just as relevant here.

• Take a breath in and then as you breathe out allow your shoulders to simply fall.
• Continue this relaxed breathing and focus on the large muscle at the top of your shoulder (trapezius). The upper traps make a line between the back of the neck and the top of your shoulder so the common tendency for the head to protrude forward will also pull the shoulders forward. As the tension in these superior fibres is reduced you’ll notice you’re shoulders start to straighten as well as fall.
• Now focus on the muscles at the side of your neck, you probably won’t notice any shape change with this, the scalenes are generally hard as a rock, but it will take a lot of the stress away from structures all around the neck and connect the upper traps with the front of the chest.
• Focus now on the area just below your clavicle, a reduction in the tension here will bring your shoulders back, opening your chest.

The left scapula is less likely to tip up over the rib cage, instead the entire shoulder complex tends to lift, either through inherent tension in the shoulder elevators, or the position of the hand and elbow. There’s a full description of these patterns in the biomechanics pages.

To stop the shoulder lifting and the elbow winging out we need to find another way to reach high up on the neck of the guitar. With the shoulder in the position we are prescribing here the humerus can rotate at the glenohumeral joint with little if any affect on the rest of the shoulder complex. Shoulder rotation is not a straightforward movement, keeping it stable and mobile through such a wide range of rotation does take some tricky engineering. The shoulder is well adapted to do this however and when there are no loads other than gravity acting on the arm this movement won’t add to the myofascial tension in your arm and shoulder.

To keep it there you need to ensure that as you move down the fretboard toward the headstock your shoulder rotates. Take a look at this short video.

The primary problem, and one that is, to varying degrees, unavoidable is the displacement of the right scapula as the arm reaches forward over your guitar. The classical position is undoubtedly the best way of avoiding this scapula displacement, unfortunately as the guitar has evolved it’s become less practical to always play it this way and we’ve been forced to adopt a less ergonomic position. The photo gallery shows some of the problems that we now face in positioning our right shoulder.

	Scapula tipping at the AC joint. Leaning the right shoulder forward places considerable strain on the AC joint and the muscles that stabilise the scapula		Right shoulder position - anteroir view. With the scapula able to follow the natural convexity of the rib cage the shoulder is under much less strain and can position the arm more freely
	Right shoulder forward - lateral view. The medial border of the scapula is pulled further away from the rib cage when leaning over a larger body guitar		Right shoulder - lateral view. Playing a larger guitar on the right leg will always put some strain on the right shoulder
	Right scapula tipping - lateral view. The smaller body of the telecaster adds shoulder retraction to an already uncomfortable mix		Right shoulder position - lateral view. Sitting up straight resolves much of the scapula tipping and the shoulder retraction.
	Right shoulder - anterior view. The larger body of my Maton gives me something to rest my shoulder on which is good because it also requires quite a lot of abduction		Right shoulder - lateral view view. My Maton now from the side and you can see the shoulder is pretty straight
	The Flying V. I was surprised at how comfortable the V was - this might be the perfect shape for a guitar,

So all of us will need to find a way to deal with this problem. One element in the solution is the maintenance of a healthy muscle tone. The very complex balance that the shoulder strikes between mobility and structural integrity requires an equilibrium across the competing force vectors. As soon as one element in this mix becomes weak, others strain to take up the slack and further problems ensue. The long pole exercise is the best one that I’ve come across but many people will prefer gym work (under supervision) or specific exercises from physical therapists.

The second element is, of course, keeping the shoulder relaxed. If you can reach with your left hand to the bottom of your right scapula you’ll probably feel the inferior angle protruding out the back. This is an indication the scapula is either winging (dragging around to the side) or tipping (sliding up over the top). There is more than likely a combination of the two. Use the upper body relaxation exercise that's included in the standing posture section to straighten the spine, open the chest and drop the shoulder. Reach around again to the inferior angle to see if the scapula has shifted.

You don’t need to totally eliminate this tipping of the scapula but you do want to reduce it. Excessive tipping will strain the acromioclavicular (AC) joint and any displacement of the scapula will strain your serratus anterior muscle as it tries to pull it back onto the rib cage. Pain that feels like it sits under the lower part of the scapula is probably related to serratus anterior strain.

If you simply pull your shoulder back to get into this position you’ll only create more tension, you need to focus on relaxing your shoulder and allowing it to fall into a more open position. The key here is to ensure that you’re sitting up straight, any thoracic bending, caused by hunching over your guitar, will contribute to scapula tipping

Fingerpickers, as opposed to classical players, have evolved a myriad of different styles and techniques based, usually, on what is most comfortable for the individual player.

If you're hand is relaxed and you can play with a relatively neutral wrist (some ulnar deviation is inevitable for most of us) and a strong neutral thumb then your wrist position is OK. Most of us will play with some flexion of the wrist which is not generally a problem.

	Fingerpicking - Lateral View. With the thumb parallel to the strings the wrist can be relatively neutral.		Fingerpicking position - lateral view. This position requires the guitar to be relatively high up on the chest.
	Right hand ulnar deviation. With my guitar so high I'm increasing the ulnar deviation of the wrist.		Fingerpicking anterior view. A smaller acoustic guitar positioned a little lower and the ulnar deviation has all but gone.
	Right thumb position - superior view. This thumb neutral thumb position also maintains a neutral wrist.		Right thumb with wrist flexed - superior view. YUK!!!

If you are going to be a competent fingerpicker you'll need a relaxed technique, at the same time the best way to achieve this is to get good at what you're doing. The technique exercises and plenty of practice will be your best friends here.

Fingerpicking requires independent movement of the thumb and usually two or three fingers. This independence of movement is not required in most other activities so we are neither constructed well anatomically or well practiced at achieving it. For this reason the focused awareness approach that we take to most other disciplines has to be modified here.

Rather than focusing on specific areas of the body the best way to free up the right hand is to focus on something else. The right hand needs to fly, with little or no conscious effort. Focusing on the sound you're making, keeping your breathe easy and slow, your shoulders soft allows the hand to switch to auto-pilot, relying on the hours of practice you've already put it in.

While you're putting in these hours and training your muscle memory so that it can take over for you like this keep these points in mind:

• Repetition will build muscle memory but it is also the primary cause of overuse. Ensure that you're practicing with your shoulders and hands soft. You don't necessarily need to play slowly, if you can play short passages up to speed then go ahead but if you try to play too fast your hand will tense up.
• When learning a new piece repeat short passages to build new movements into your muscle memory.
• Get enough rest breaks, intersperse the repetitive movements with other activities, either a warm up exercise, any of the stretches or mobilisations for the forearm or the baoding exercise.

We already know that the most efficient position for the wrist is a neutral one. Variations from this neutral position will depend on the angle that you attack the string, whether or not you anchor your wrist, and the size and position of the guitar.

The analysis on the biomechanics pages will help you determine how much you're prepared to vary from this neutral position. The following strategies will be helpful in any case.

	Flatpickpicking - Anterior View. This neutral wrist position allows easy access to the strings		Flatpicking with the guitar lower - anterior view. With the guitar lower the forearm brings the hand in at a different angle so the plectrum attacks the strings slightly differently
	Right hand anchored to the bridge. This position can help locate the strings but will restrict the movement of your hand		Scratch plate anchoring. Anchoring on the scratch plate allows a little more room to move than on the bridge
	Right hand - anterior view. Without anchoring on the bridge and the guitar at the right height a neutral right wrist is easy.

Wrist motion

We’ve all taken one end of a piece of rope and flicked it to create a wave. If your wrist is stiff you might get a staccato type ripple, but if it's both loose and firm and you initiate a strong movement from your shoulder, or better still your legs, you’ll have a stronger, more consistent movement along the rope.

The same goes for picking, you need to pick a string with this sort of intent and fluidity. Again we have an application for our focused awareness skills.

• Without attacking the string, take your plectrum and make a flicking motion, as you would if you were flicking a rope.
• The impetus for this motion will start at the elbow even though the elbow doesn’t actually move. Instead imagine a wave, slowly gaining momentum and breaking at the wrist as it would as it reaches the shore.
• With this same intent play a few notes on your guitar.
• The energy released at the wrist needs to continue up the string to the left hand which then “catches” and absorbs it. The idea is that nowhere along this continuum is the wave blocked.

This technique is more thoroughly thrashed out in the Practice pages.

To anchor or not to anchor?

There are definite disadvantages, biomechanically, in anchoring. It tends to lock the hand in one position and wrist anchoring can induce an unhealthy hyperextension.

That said some people will find it helps them, their playing style may be more suited to it and it may help the hand to relax, simply because it's easier to play that way. If you do rely on this technique and have ever tried to play without it you’ll have found your hand tense up and your playing slow down.

An anchored wrist is more of a problem than the common practice of resting your little finger on the scratch plate because it reduces the mobility of your hand more and importantly it creates hyperflexion in the wrist. When you're deciding whether it's worth this significant change to your technique look first at how much of a problem it is.

The main question is how much hyperextension does it create. If you’re playing an electric guitar on a long strap it’ll be easier to maintain the straight wrist, keep an anchor point either at the bridge of the scratch plate, and play with a soft relaxed forearm and hand. If you then lift the hand away from the guitar be prepared for what is likely to happen.

This will take lot of practice to get right, the unfamiliar position, the difficulty finding the strings and the energy required to lift your hand away from the guitar will build a lot of extra tension in your arm. It may be worth it but you’ll need to have your shoulders soft and be very confident that you can keep the entire arm and hand relaxed as you practice.

If on the other hand you’re playing an acoustic guitar, or a 335 on a shorter strap, it’s an entirely different ball game. Now having the wrist on the bridge will cause it to lift slightly into an extended position, just enough to lock up your wrist and finger extensors, before you even hit a note. The advantage now of getting your wrist away from the bridge will definitely be worth the effort, and it won’t be as difficult as it would be playing a Les Paul down around your knees.

Getting the wrist off the bridge

Make sure that you’ve first looked at the previous section on shoulder positioning. Getting your wrist away from the bridge is not a complicated matter but it does take some practice and will feel awkward at first. If your shoulders are soft and that you are confident that you can keep your hand and arm relaxed as you practice you’ve done the hard yards.

Position your guitar high enough that you can keep your wrist in a neutral position (if it’s too low you’ll be force into radial deviation)

Ensure that you’re holding your plectrum correctly and your hands are soft. I’d suggest that you start with the flatpicking technique exercises. Start with the simpler ones, play very slowly and stop once you’re aware of any tension in your shoulder or arm.

These exercises rely heavily on your focused awareness skills, having these honed will be a real advantage in making this significant adjustment to your technique.

Right elbow

The right elbow will flex as much as it needs to get the hand in the right position, it is well adapted to do this and as long as any scapula tipping hasn’t rotated the humerus it shouldn’t be under any strain at all. Right elbow dysfunction is related to the muscles that control the hand and wrist that originate either at or near the elbow.