The Repercussions of Percussion – Don Mathew, MD FAAPMR – 3/7/21
To my fellow drummers, I feel your pain…literally. I am a practicing physician that completed medical school about ten years ago and subsequently trained at Northwestern Medicine into a specialty called physical medicine and rehabilitation, also known as physiatry, with a background in kinesiology and sports medicine. That’s right! I am a musculoskeletal specialist, the doctor you go see for drumming related injuries. It so happens that I’m also an amateur drummer myself. I’ve been playing for some years now and currently gig around Chicago in a pop punk band, called Status Code.
We, as drummers, are no strangers to pain or injury. The nature of our talent is physically demanding and as such, it acquires tangible risk over time. Sometimes, we overlook and even fight through pain to complete the job at hand. Depending on the type of music, playing style, lack of rest, technique, we absorb a tremendous amount of energy that is produced while playing, which is then exerted onto our fingers, wrists, elbows, shoulders, knees, feet, etc. This can lead to pain and strain, with poor technique reigning as the highest culpability. From my own personal experience and clinical practice, I’ve put together a consensus on this unique realm.
Many of us start off wailing away on the drums with blithe disregard. We cannot help but idolize drummers who play with no regrets, as they command all parts of the kit. Every now and then, we also see those that can slay a track but without the most sound technique. Looking and sounding cool does not always mean quality and it certainly doesn’t imply security. Given the circumstances, even playing efficiently and accurately doesn’t guarantee a lack of susceptibility.
The forearm consists of muscles primarily for flexion, extension, supination, and pronation movements of the wrist. In match grip, the thumb is essential for grasp and maintaining a fulcrum. Playing contrived with the thumbs up requires supination and ulnar-deviated flexion in a repetitive non-neutral fashion, which can lead to wrist and arm strain. Irregular patterns that don’t adhere to their natural pathways not only limit fluidity, but also cause the system to incur excess stress. This leaves our muscles, bones, ligaments, and tendons vulnerable to injury. Physiologically speaking, tendinous and particularly ligamentous structures, have considerably less bloody supply than muscles. Therefore, injuries of this nature take longer to heal in comparison to muscle. With the wrist being the most commonly affected body part in drummers, positioning the palms down tends to be more logical in terms of anatomy and optimal in terms of safety without sacrificing performance. The Moeller method exemplifies fundamental and intended movement patterns. Bruce Becker has some great technical videos on this.
In contrast, a traditional grip in the non-leading hand utilizes predominantly pronation with the thumb being a major component in generating power. The range of dynamic movement is superior in the field drum when compared to match grip, such as when comping or doing stick on stick phrases in jazz. Interestingly, this then truncates when reaching peripherally to the toms or cymbals. This is because the wrists and forearms naturally pronate as the arms reach forward, as a joint protective mechanism. Think of deadlifting, with a preference of combined over and under hand grips when the weight is close to the body. As the weight traverses away from the body, an overhand match grip becomes superior for function. With that said, anything can be played with any grip style. So based on the genre, anatomy, or preference, one style may be better suited for any one individual. A traditional grip is prone to injury at the CMC joint of the thumb and usually a result of overplaying. Pain there is predominantly experienced as aching and constant, exacerbated with activity. Repetitive strain injuries are also the case with small bones of the feet, Achilles heel, calves, and hip flexors, as seen in the fast pace of metal drumming with use of double bass. Playing hard obviously generates higher reactive forces. Consequently, prolonged exposure to this vibration impact not only overloads the soft tissues, but the deeper structures as well. Keeping the foot in constant contact with the pedal allows for a smoother transfer of energy in a closed chain while minimizing impact, further reducing injury risk. Knees should be bent just over ninety degrees. This applies to both heel up and heel down techniques. In general, overuse injuries should be approached with strict rest depending on the severity, before commencing practice.
A novice drummer tends to play stiffer and with more proximal limbs. In the arms, this is frequently seen in the shoulders, particularly with the lead hand. Good muscle tension accompanies a readiness, from where shoulders are down and relaxed. Poor form further aggravates the ball-and-socket joint, such as when over-reaching to swing on an outlying ride cymbal. Shoulder pain and strain, often in the bicipital tendon, can develop. Impingement of the supraspinatus tendon, a component of the rotator cuff, is another common phenomenon resulting from repetitious high reaching and internal rotation movements. Because the shoulder is only one of the moving parts in the entire arm during a drum strike/stroke, any insult along this kinetic sequence can significantly alter the biomechanics involved in propelling the stick. In haste, we all strive to reach a level of sophistication heeded only by our drum gods, such as the likes of the almighty Dennis Chambers or the infamous prodigy Tony Williams. However, the finesse of ghost notes and fine movements of stick rebound, executed from the fingers and wrist only advance with maturity. Poetry in motion, as they say, is a culmination refined by time and practice. Laterality of the dominant side is also common in beginners. Ambidexterity and independence of limbs are conventionally found in creatures of extensive practice and habit. Symmetry in position and stick height are essential for sound evenness and uniform reproduction. In match grip, sticks that align equidistant at around 90 degrees towards the center of the snare drum head is considered ideal for consistency and stability. At zero or rest, the elbows should lie just obtuse, with this being the start or return position. In cross stick patterns and other asymmetric dispositions, good form is key.
Numbness, tingling, and even weakness of the hands are unfortunately all too familiar to drummers. This type of repetitive strain injury is known as carpal tunnel syndrome, which comes from pressure on the median nerve in the carpal tunnel of the wrist. Definitive testing is done through electromyography (EMG), which is performed by a health specialist, such as myself. However, the majority of cases are diagnosed clinically and treatment is often trialed through splinting, positioning the wrists at neutral. Another approach I’ve found to help in my practice, is having patients focus on strengthening the wrist extensors. This helps to create a balance to the dominant wrist flexors. There are now manufactured devices that assist with this kind of exercise. Severe cases that involve a loss of grip strength may need surgical intervention. Loosening your grip, or even just easing your index finger up on the stick, can help profoundly. I tend to counsel my patients of percussion the obvious; relaxed playing is the best playing.
One of the most common and devastating injuries seen in drummers is tendinitis/tendinosis. It is a general term for an inflammatory condition of the tendon. It can produce significant pain that can interfere with function. Routinely acquired through excessive use, it can be acutely treated with RICE (rest ice compression elevation). As previously mentioned, due to its blood supply, the healing process is longer and the overwhelming majority of cases progress chronically with frequent relapses. This means increased rest time for recovery. Personally, I was affected by one, an enthesopathy involving the ECRB (extensor carpi radialis brevis) tendon known as lateral epicondylitis, more commonly referred to as tennis elbow. The intense, gnawing and nagging pain on the outside of my elbow was intolerable. Much less common in drummers is golfer’s elbow, where the pain arises from the inside of the elbow. Rest, ice, creams, stretching, anti-inflammatory medications, all could not sufficiently alleviate my symptoms as it tediously healed. With constant flare ups, in part due to an effort to finish gigs and recordings, it took close to a full year to adequately recover. In general, lateral epicondylitis can last weeks to months, but can persist beyond a year if not properly tended to. Tennis elbow braces are useful devices that anchor forces distal to the affected site, relieving tension on the tendon attachment. More invasive measures include peppering a steroid injection into the tendon or administering a procedure called platelet-rich plasma (PRP), both of which are shown to be effective treatments. Foam rolling to the designated area is another great adjunct that I’ve personally found to be fruitful. Occupational therapy is also an excellent option to precisely focus on the upper limb with many successful methods, including the utilization of hot and cold modalities, ultrasound, and electrical stimulation.
Due to the variability among people’s practice ethic, style, body habitus, etc., the best advice is to be wary of your technique. Preexisting conditions are also a strong consideration for strategizing your approach. Some of us that play have arthritis, scoliosis, different limb lengths, longer lever arms, thinner fat pads on our soles, decreased muscular potential, and many other notable discrepancies. This where ergonomics maximizes efficiency, while being protective. Think of the Alexander technique applied here. Be mindful of a good upright posture and don’t overreach while playing. I instruct my fellow drummers the following: play in the pocket while sitting in your pocket. This helps to prevent neck and back pain that many seasoned drummers suffer from. It also improves pivoting to the peripheral parts of the kit. Moreover, I encourage them to strengthen their core. This will aid to displace forces away from the posterior elements of the back, alleviating load on the erector spinae and vertebrae. The shoulders oftentimes fall prey to continuous extraplanar motion. At the risk of sounding asinine and lacking medical legitimacy, I reluctantly advise patients to imagine having T-rex arms while reaching. A good rule of thumb is not to fight through the pain and intuitively listen to your body. Be aware of the consequences. Develop good habits, such as warming up first through rudiments before static stretching. This is especially true for gigs, where you are obligated to play through a set no matter what. There is a myriad of how-to online resources and videos from our favorite drummers that display this, i.e., Jojo Mayer’s clapping exercise. If playing hard is imperative to the task at hand, thoroughly consider using mics. Additionally, don’t forget ear protection!
With almost no research available in this subset, there is no precise description of what entails an optimal practice. It is crucial to understand that substantial practice with high repetition requires ample rest. Without it, the balance is shifted to where tissue breakdown and injury prevail. Preserve the skills you have by being informed and yielding to a quality health competency. Occupy a sense of routine and regularity in your practice. Proficiently adjust the volume and intensity of your session, as needed. Changing the focus of your practice is another clever tactic. Incorporating a day of heavy arms followed by a day of heavy legs warrants minimal deliberation. Similarly, having an injury does not mean stop playing. Patience is a virtue, but telling that to a drummer is like telling a cow not to graze. If one part of your body is out of commission, concentrate on another unaffected part. So, if you hurt your hand, work on your foot techniques and vice versa. With time, practice can be facilitated with controlled motion. Conducting everything in moderation is principal, particularly after an injury. A healthy amount of regular cardio will provide the stamina and conditioning needed to endure lengthy sessions. Hydration and nutrition are also vital to playing status. Feed your muscles the fuel it needs to execute laboriously. Prevention is the best remedy and being prepared will immensely improve your playing ability and longevity. In any of the aforementioned scenarios, always seek the professional opinion of a medical provider before determining what are the best options for your diagnosis and treatment. Drum on and prosper!
Don Mathew, MD FAAPMR email