The Structure and Movement of Clarinet Playing D.M.A

Home , Clarinet, Hamate bone, Lumbosacral joint, Mass (Bernstein), Nuchal ligament, Procerus muscle

The Structure and Movement of Clarinet Playing

D.M.A. DOCUMENT

Presented in Partial Fulfilment of the Requirements for the Degree Doctor of Musical

Arts in the Graduate School of The Ohio State University

Sheri Lynn Rolf, M.D.

Graduate Program in Music

The Ohio State University

2018

D.M.A. Document Committee:

Dr. Caroline A. Hartig, Chair

Dr. David Hedgecoth

Professor Katherine Borst Jones

Dr. Scott McCoy

Copyrighted by

Sheri Lynn Rolf, M.D.

2018

Abstract

The clarinet is a complex instrument that blends wood, metal, and air to create some of the world’s most beautiful sounds. Its most intricate component, however, is the human who is playing it. While the clarinet has 24 tone holes and 17 or 18 keys, the human body has 205 bones, around 700 muscles, and nearly 45 miles of nerves. A seemingly endless number of exercises and etudes are available to improve technique, but almost no one comments on how to best use the body in order to utilize these studies to maximum effect while preventing injury.

The purpose of this study is to elucidate the interactions of the clarinet with the body of the person playing it. Emphasis will be placed upon the musculoskeletal system, recognizing that playing the clarinet is an activity that ultimately involves the entire body. Aspects of the skeletal system as they relate to playing the clarinet will be described, beginning with the axial skeleton. The extremities and their musculoskeletal relationships to the clarinet will then be discussed. The muscles responsible for the fine coordinated movements required for successful performance on the clarinet will be described. With this information in mind, methods of maximizing the use and coordination of the body while playing the instrument will be presented. It will be shown that efficient use of the body not only contributes to ease of playing the clarinet but also minimizes the risk of injury.

Acknowledgments

A mere “Thank You” seems insufficient to express the gratitude I would like to express to those who have participated in my odyssey. My Committee members at

The Ohio State University School of Music deserve special recognition. Dr. Caroline

Hartig, Dr. David Hedgecoth, Professor Katherine Borst Jones, and Dr. Scott McCoy have all been sources of support and encouragement. Dr. Hartig, as my teacher and advisor, merits special recognition for the role that she has played during my study at

OSU. Not only has she guided me to a higher level of clarinetistry, she has also led me through a seemingly endless labyrinth of paperwork, academic requirements, and deadlines. Thank you, Dr. Hartig!

A special word of thanks is extended to Professor Dale Beaver for introducing me to the Alexander Technique. This is a program that should be included in every school of music. Thank you, Dale for teaching me the real meanings of balance and poise.

To Dr. William H. Saunders and Dr. David E. Schuller who served as my mentors during my residency in Otolaryngology-Head and Neck Surgery at The Ohio State

University, thank you for setting such high standards. I am especially thankful for all the patients who have granted me the privilege of participating in their care.

Most of all, I want to thank my husband, Bradley J. Finn. As my soul mate, he has been my GPS for this journey. For his love, his encouragement, and his profound understanding of what music and playing the clarinet mean to me, I am eternally grateful. Brad, I love you!

iii

Vita

1971...... Campbell County High School

1975...... B.M. Applied Clarinet, University of Louisville

1978...... B.S. Biological Sciences, Northern Kentucky State University

1981...... M.D. University of Louisville

2014...... M.M. Clarinet Performance, University of Montana

Publications

Kern, J. A., Milbrandt, T. A., Rolf, S., & Tribble, C. G. (1997). Resection of multiple mediastinal paragangliomas with cardiopulmonary bypass. The Annals Of Thoracic Surgery, 64(6), 1824-1826.

Rolf, S.L. Confessions of a horse clinic junkie. (1998) American Cowboy, 66-67.

Rolf, S.L. The legend of Tack Crawford’s saddle. (2003) Montana Magazine, 177, 85-87.

Rolf, S. L., Kratz, R. C., Tanner, G. R., & Crissman, J. (1980). Primary lymphoma of the thyroid and Hashimoto’s thyroiditis. The Journal Of The Kentucky Medical Association, 78(5), 263-266.

Rolf, S. L., Reed, S. M., Melnick, W., & Andrews, F. M. (1987). Auditory brain stem response testing in anesthetized horses. American Journal Of Veterinary Research, 48(6), 910-914.

Fields of Study

Major Field: Music

Table of Contents

Abstract ...... ii Acknowledgments...... iii Vita ...... iv Publications ...... iv Fields of Study ...... iv Table of Contents ...... v List of Figures ...... viii Chapter 1: Introduction ...... 1 Chapter 2: The Skeletal System ...... 5 The Axial Skeleton ...... 5 The Spine ...... 6 The Thoracic Spine and Rib Cage ...... 16 The Lumbar Spine ...... 19 The Sacrum and Coccyx ...... 22 The Skull ...... 25 The Mandible ...... 30 The Hyoid ...... 32 The Upper Extremities ...... 33 The Shoulder Complex ...... 34 The Wrist and Hand ...... 43 The Pelvis ...... 52 Chapter 3: The Muscular System ...... 58 Muscle Structure and Function ...... 58 Muscles of the Embouchure ...... 61 The Muscles of Mastication ...... 65 The Tongue ...... 68 Muscles of the Palate and Pharynx ...... 71 Suprahyoid and Infrahyoid Muscles ...... 73 Muscles of the Neck ...... 75

Muscles of the Shoulder ...... 79 Muscles of the Elbow ...... 81 Muscles of the Wrist and Hand ...... 84 The Thorax and the Muscles of Respiration ...... 89 Chapter 4: Posture ...... 101 The Alexander Technique ...... 114 Feldenkrais Method ...... 115 Pilates ...... 116 Yoga ...... 116 Rolfing ...... 117 Body Mapping ...... 117 Posture of the Head and Neck ...... 118 Posture of the Hand ...... 121 Chapter 5: What Could Possibly Go Wrong? ...... 129 Postural Issues ...... 129 Playing Related Musculoskeletal Disorders ...... 131 Carpal Tunnel Syndrome ...... 133 Ulnar Nerve Entrapment ...... 134 Temporomandibular Joint Dysfunction ...... 136 Thoracic Outlet Syndrome ...... 137 Focal Dystonia ...... 139 Miscellaneous Conditions ...... 140 Conclusion ...... 142 References ...... 143 Appendix A: Anatomical Directions, Planes, and Landmarks ...... 150 Appendix B: Summary Chart of Muscles Relevant to the Clarinetist ...... 153 Appendix C: Spinal Nerves and Nerves of the Upper Extremity ...... 176

List of Tables

Table 1. Table of Skeletal Muscles………………………………………….153

vii

List of Figures

Figure 1. Illustration from Clarinetist's Compendium by Daniel Bonade...... 2 Figure 2. Axial Skeleton (highlighted in green) consists of the skull, mandible, hyoid bone, spine and rib cage...... 6 Figure 3. Superior view of second lumbar vertebra (L-2)...... 8 Figure 4. The spine: anterior view (left) left lateral view (middle) and posterior view (right)...... 10 Figure 5. The cervical spine, seen in lateral view...... 12 Figure 6. The atlas viewed from posteriorly (upper image) and from above (lower image)...... 13 Figure 7. The axis as viewed from above (upper image) and from posteriorly (lower image)...... 14 Figure 8. Posterior-superior view of the atlanto-axial relationship...... 14 Figure 9. When the head is balanced, as on the right, less muscular activity is necessary to maintain its position...... 15 Figure 10. An increased load is placed upon the neck as the head is moved forward...... 15 Figure 11. Superior and lateral views of thoracic vertebrae demonstrating the superior and inferior costal facets (demi facets), points of attachment for the heads of the ribs...... 17 Figure 12. The thoracic spine (highlighted in green)...... 18 Figure 13. The twelve ribs on the left side of the body are highlighted in green in the illustration on the left...... 19 Figure 14. The lumbar spine...... 20 Figure 15. An exaggerated lumbar lordosis is seen in a clarinet soloist. He also exhibits a forward head position...... 21 Figure 16. The effects of pelvic on posture are seen both above and below the pelvis...... 22 Figure 17. A herniated disc...... 22 Figure 18. The sacrum as seen anteriorly (left) and posteriorly (right)...... 24 Figure 19. The coccyx is seen on the left from anteriorly...... 24 Figure 20. Bones of the calvarium...... 26

viii

Figure 21. The occipital bone is shown in the illustration on the top...... 28 Figure 22. The atlanto-axial joint...... 28 Figure 23. The right maxilla is seen in lateral view (highlighted in green) in the illustration on the left. The middle illustration views the left maxilla from inferiorly...... 29 Figure 24. CT scans of the maxillary sinuses...... 30 Figure 25. The mandible and its parts...... 33 Figure 26. The hyoid bone, highlighted in green, is shown in its anatomic position in the image on the left...... 35 Figure 27. Components of the right shoulder complex viewed from anteriorly (left),posteriorly (middle), and laterally (right)...... 36 Figure 28. The right clavicle, highlighted in green, as viewed from above...... 37 Figure 29. The right scapula is a roughly triangular shaped bone as is seen in the anterior (left) and posterior (right) views above...... 38 Figure 30. A posterior view of the right humerus is highlighted in green...... 40 Figure 31. In the image on the left, the right ulna is shown in isolation in medial view demonstrating the trochlear notch...... 41 Figure 32. The ligaments of the right elbow are highlighted in green in the image on the right...... 42 Figure 33. The bones of the forearm...... 45 Figure 34. The articular surface of the distal right radius is highlighted in light green...... 46 Figure 35. The proximal row of carpal bones of the right wrist viewed from anteriorly...... 48 Figure 36. The distal row of carpal bones in the right wrist...... 49 Figure 37. The first metacarpal is highlighted in green...... 50 Figure 38. The third metacarpal is highlighted in green...... 51 Figure 39. The ilium (left), ischium (middle), and pubis (right) are highlighted in green...... 53 Figure 40. The pelvis is shown with the cartilaginous disc of the pubic symphysis highlighted in green...... 54 Figure 41. The right femur is highlighted in green. The medial inclination from the hip to the knee is readily apparent. The slight bowing is much more subtle...... 55 Figure 42. Bones of the human foot...... 56 Figure 43. The arches of the foot provide a stable base for the clarinettist to stand upon...... 57

Figure 44. Myofilaments composed of either actin or myosin join together to form sarcomeres...... 59 Figure 45. The sarcomere is the contractile unit of the muscle...... 60 Figure 46. Muscles involved in formation of the clarinet embouchure...... 63 Figure 47. The relationships of the super pharyngeal constrictor (left), buccinator (middle), and orbicularis oris (right)...... 65 Figure 48. The muscles of mastication...... 68 Figure 49. Three of the extrinsic muscles of the tongue...... 70 Figure 50. The superior, middle, and inferior pharyngeal constrictors...... 73 Figure 51. The hyoid with some of its muscles...... 75 Figure 52. This diagram illustrates the vectors of pull of the muscles attached to the hyoid bone...... 76 Figure 53. The “guy wire” effect produced by the levator scapulae, a posterior neck extensor, and the scalenes (posterior, middle, and anterior), which are anterior neck flexors...... 79 Figure 54. Muscles of the right shoulder, anterior view (left) and posterior view (right)...... 82 Figure 55. Flexors of the elbow...... 84 Figure 56. Flexor tendons are shown inserting on the digits...... 86 Figure 57. This diagram schematically illustrates the anatomy of the pulley and flexor tendon relationships found in digits II-V...... 88 Figure 58. The diaphragm seen from below...... 90 Figure 59. The diaphragm in anterior view...... 94 Figure 60. The rectus abdominis is demonstrated along with its three transverse tendinous insertions...... 95 Figure 61. The external abdominal oblique muscle...... 96 Figure 62. The internal abdominal oblique muscle...... 97 Figure 63. The transverse abdominis muscle is the deepest of the paired abdominal muscles involved in respiration...... 98 Figure 64. The quadratus lumborum is in the lower back where it stabilizes the lower back...... 99 Figure 65. Rigid military posture………………………………………………104

Figure 66. The three arches of the foot ……………………………………….. 105

Figure 67 Effects of pronation and supination of foot…………………………106

Figure 68. The effects of overpronation of the foot ...... 107 Figure 69. Poor sitting postures...... 108 Figure 70. Effect of pelvic tilt on lumbar curvature...... 108 Figure 71. These two penguins exhibit two very different postures...... 110 Figure 72. Disk problems in the spine may arise as a result of faulty posture. .... 111 Figure 73. This chart represents an effort toward matching musician size with chair seat height by considering age and grade level...... 113 Figure 74. These three women exhibit poise and balance...... 115 Figure 75. Each inch that the head moves forward of its balance point atop the spine effectively results in an increased load of about 10 pounds on the spine...... 119 Figure 76. The clarinetist in the foreground demonstrates relatively good head posture...... 121 Figure 77. An increased load is placed upon the neck as the head is moved forward...... 121 Figure 78. The three arches of the hand...... 122 Figure 79. Three arches of the hand, palmar surface view...... 123 Figure 80. The tennis ball (left) has a diameter of 2.7 inches while the racquetball (right) has a diameter of 2.25 inches...... 125 Figure 81. The racquetball is seen in the author's hand, secured by a Velcro strap...... 125 Figure 82. The author is seen playing the clarinet while using a racquetball device in each hand...... 126 Figure 83. The Kooiman Maestro2 thumb rest...... 128 Figure 84. Upper and Lower Crossed Syndromes. These occur due to muscle tightness and weakness as indicated...... 130 Figure 85. Carpal tunnel syndrome is due to compression of the median nerve within the carpal tunnel. Surgical release of the transverse carpal ligament to relieves the compression...... 134 Figure 86. The ulnar nerve is demonstrated in a normal cubital tunnel. It can become compressed here to produce cubital syndrome...... 136 Figure 87. The temporomandibular joint exhibits both hinge and gliding movements...... 137 Figure 88. Thoracic outlet syndrome...... 139 Figure 89. Directional References Used In Anatomical Descriptions………… 150

Figure 90. Surface Anatomy and Landmarks of the Human Body………. …... 151

Figure 91. Anatomical planes of the human body……………..……………….152

Figure 92. Spinal nerves: sensory and motor levels…...……………………….176

Figure 93. Cervical plexus…………………………...…………………………177

Figure 94. Sensory innervation of the upper extremity……..………………….178

Figure 95. Brachial plexus (The electrician’s nightmare)………………………179

Figure 96. Sensory and motor innervation of the median nerve………………..180

Figure 97. Sensory and motor innervation of the ulnar nerve…………………..181

xii

Chapter 1: Introduction

18 keys, the human body has 205 bones, around 700 muscles, and nearly 45 miles of nerves. Through the years, numerous articles and books have been written about how the clarinet should be played, but most pay little attention to the body of the person playing the clarinet. A seemingly endless number of exercises and etudes are available to improve technique, but almost no one comments on how to best use the body to promote ease of playing while reducing the potential for injury. Many of the descriptions of body position and breathing in clarinet pedagogical literature are incomplete or even inaccurate. Explanations of why certain instructions about body use are given, are seldom to be found.

Daniel Bonade is considered among the most influential figures in the development of an American style of clarinet playing. (Kycia, 1999) His Clarinetist’s Compendium begins with the statement that “Correct posture in playing the clarinet is most important…” (Bonade, n.d.) He goes on to describe the posture for playing the clarinet, “ Body well erect, head looking horizontally forward. The clarinet then should be brought upward to the mouth by the forearms, without bowing the head toward the mouthpiece.” (Ibid.) While this is good advice, there is no explanation of why this makes sense from an anatomical point of view. He goes on to state, “Upper arms should stay perpendicular to the body.” (Ibid.) This is an obvious anatomical

misstatement. He clearly meant ‘forearms,’ not ‘upper arms.’ He includes a line drawing of ‘correct posture’ in his text. Unfortunately, the drawing includes postural flaws most notably a forward head position.(Figure 1.)

Figure 1. Illustration from Clarinetist's Compendium by Daniel Bonade.

Frederick Thurston advises the clarinetist to “Stand up straight with the body thoroughly relaxed…It is best to play as much as possible standing up.” (Thurston,

1985) This is excellent advice, as will be demonstrated in the following chapters, but no rationale is given in Thurston’s text regarding why these directions should be followed. No illustrations are presented.

Throughout his discussion on the importance of relaxation to the clarinetist, Keith

Stein correctly alludes to the interconnectivity within the human body while never actually describing it as such. (Stein, n.d.) He describes strain as being ‘contagious’ in that it may spread throughout the body to adversely affect one’s clarinet playing.

(Ibid.) He correctly describes a sequence of tension beginning in the lips, continuing into the tongue, and extending into the throat. (Ibid.) He also provides a very nice description of correct hand posture for playing the clarinet. (Ibid.) His text fails to give any anatomical or physiological justification for his astute observations.

Some references to breathing and breath support in the clarinet literature seem to be more grounded in mythology than physiology. There are only three sentences in

Pamela Weston’s book, The Clarinet Teacher’s Companion, under the subheading,

“Playing Position.” (Weston, 1976) She advises that the clarinetist should sit,

“…slightly forward, so that the breath does not have to come ‘up hill.’” (Ibid.) No attempt is made to explain what is meant by this rather curious statement. A technique of breathing recommended by Ridenour is described as the “Aerosol Can” method of blowing. (Ridenour, 2002) This technique, he states, “…is characterized by a combination of full and perpetual diaphragmatic contraction…” (Ibid.) There are schematic diagrams accompanying the text, but these fail to clarify the anatomy involved or the process by which “full and perpetual diaphragmatic contraction” can possibly be attained. Stubbins, in The Art of Clarinetistry provides a nice explanation of respiration which dispells much of the misinformation still heard about the function of the diaphragm. (Stubbins, 1974) His text does not address body position nor does he include any illustrations to enhance his descriptive writing.

Relaxation is emphasized by David Pino. (Pino, 1980) He offers the term, “muscular alertness” instead of tension, and gives three areas of the body in which “muscular alertness” is necessary while playing the clarinet. (Ibid.) These are the thumb of the right hand, the muscles of the embouchure, and the the “airflow-supporting muscles around the waist-line.” (Ibid.) He also describes airflow, but the mechanics and anatomy of respiration are not included in his discussion. (Ibid.)

These examples should illustrate that information about clarinet playing is frequently presented without considering the structure and movement of the human body that is actually playing the instrument. Some statements seem to be based more upon oral

traditions passed down through generations of clarinetitsts than scientific fact. Once a rudimentary understanding of how the body is is organized and moves has been attained, it should be possible to present information to future generations of clarinetists leaading to more effortless, injury-free clarinet playing.

Chapter 2: The Skeletal System

The bones of the skeletal system combine to form the body’s framework. In many ways the skeleton is similar to the scaffolding of a building, providing a three dimensional blueprint around which the body’s other parts are arranged. But this analogy is only partially correct. The scaffolding of a building does not move. The human body, however, is capable of many kinds of movement from gross motor movements like swinging a sledge hammer to the most delicate surgical manoeuvres and musical trills. Obviously, joints are required for movement, and there are several types in the human body, but there must also be a stable balanced platform from which movement can occur. When the clarinetist allows his/her skeletal framework to provide him/her with a stable balanced platform from which to perform, the result is reduced muscular tension and greater ease of playing.

The Axial Skeleton

The axial skeleton consists of the skull, mandible, hyoid bone, spine, and rib cage

(Neumann D. A., 2010) as shown in Figure 1 (highlighted in green). Each component of the axial skeleton is of importance in providing a stable balanced platform for playing the clarinet.

The Spine

Because the spine may be thought of as the central axis or core of the clarinetist’s body framework, discussion of the axial skeleton will begin here. The spine is composed of 33 vertebrae: 7 cervical; 12 thoracic; 5 lumbar; 5 sacral (fused); and 4 coccyx. (Dimon, 2011; Norris, 2015) Twenty-four vertebrae, the cervical, thoracic, and lumbar, are moveable while the remainder are not. It is important to recognize the basic construction of the individual vertebrae in order to understand how the spine works as a whole.

Each vertebra exhibits a structure designed to serve a number of functions. Figure 3 is a superior view of the second lumbar vertebra, L2. The body of the vertebra is situated ventrally, or toward the front of the body. The vertebral bodies are thick,

consistent with their function of weight bearing. (Neumann D. A., 2010) The spinous processes are located on the dorsal aspect of the vertebrae. These are what one feels when running a finger up or down one’s spine. Because the spinous processes are the part of the spine with which most people are aware, it is understandable that many individuals conjure up a mental image of the spinous processes as weight bearing structures. In point of fact, however, the spinous processes on the dorsal aspect of the spine are sites of muscle and ligament attachment with no significant involvement in weight bearing. (Dimon, 2008) It is their function to help protect the spinal cord.

Muscles and ligaments also attach to the transverse processes of the vertebrae.

Pedicles extend posteriorly from the body of the vertebra and are connected together by the lamina. The posterior aspect of the vertebral body, the pedicles and lamina, together create the vertebral foramen (Dimon, 2011) through which the spinal cord passes as it courses down the spine. Collectively, this portion of the vertebra is referred to as the arch. The spaces between the pedicles are known as intervertebral foramina. It is through these foramina that the spinal nerve roots pass. The articular facets form joints between adjacent vertebrae.

Even though all vertebrae share these general properties, not all vertebrae are alike.

Moving inferiorly from the atlas (C-1) at the top of the spine, the sizes of the vertebrae increase. This increase in size is most noticeable in the height and depth of the vertebral bodies as is clearly demonstrated in the left lateral view of Figure 3. This finding is consistent with the increasing amount of weight that the vertebrae lower in the spine must support. (Dimon, 2011) Notice that the vertebral bodies below C-2 are separated by intervertebral discs. These thick fibrocartilaginous structures act as spacers and shock absorbers within the spine. (Neumann D. A., 2010)

Figure 3. Superior view of second lumbar vertebra (L-2). 1-Body; 2-Trnsverse process; 3-Articular facets; 4-Spinous process; 5-Arch. In the human body, the vertebral bodies are situated ventrally and bear weight while the dorsally located spinous processes protect the spinal cord and are not a part of the weight bearing apparatus. (Hanson, J.T., Netter’s anatomy coloring book, plate 2-E © 2010. )

Figure 4 depicts the entire spinal column in anterior, left lateral, and posterior views.

The spine is generally considered as having four distinct regions: cervical, thoracic, lumbar, and pelvic. Each of these sections of the spine demonstrates a characteristic curvature as may be seen in the left lateral view of the spine in Figure 4. The cervical spine has a curve which is convex anteriorly, known as lordosis. The direction of the curvature is reversed in the thoracic spine so that it is concave anteriorly, a configuration referred to as kyphosis. In the lumbar spine, the direction of the curve becomes lordotic once again. Finally, in the pelvic region, the curvature is kyphotic.

This gives an “S” shape to the spine as viewed laterally. Only the thoracic curve is present at birth; the remainder develop as the body assumes an upright posture. The human, as the only vertebrate with an upright posture, is the only vertebrate whose spine exhibits all of these curves. (Dimon, 2011) Thus, the human spine is a

customized system designed for weight bearing and movement from an upright position.

The cervical spine, highlighted in green in Figure 5, is comprised of the seven smallest moveable vertebrae in the body. It has a natural lordotic curve (convex anteriorly). Unique to the cervical vertebrae are the presence of transverse foramina in their transverse processes. The vertebral arteries pass through these foramina as they travel to the brain. (Neumann D. A., 2010) The lower five cervical vertebrae share morphological similarities with the other moveable vertebrae lower in the spine even though they are smaller and far more mobile. These vertebrae, C-3 through C-7, are sometimes referred to as the lower cervical vertebral column. These bones have dense rectangular bodies that are wider from side to side than from anterior to posterior. The lower cervical vertebrae have a number of important functions. These five vertebrae support the load of the head, keep the head upright, withstand the muscular forces imposed upon them, and do all of this while maintaining a high degree of mobility for the head. (Oatis, 2009)

Figure 4. The spine: anterior view (left) left lateral view (middle) and posterior view (right). Note the increasing size of the vertebrae from superior to inferior. As the vertebrae increase in size so too does the thickness of the intervertebral discs. Note also the curvatures of the spine. (© 2018 Elsevier Inc. All rights reserved. www.netterimages.com Used with permission.)

The cervical vertebrae C-1 and C-2 are named the atlas and axis, respectively.

Collectively, they constitute the cranio-cervical region of the spine. They have distinctive structural features corresponding to their unique functions. The atlas, C-1, is essentially a ring of bone which functions to support the head. Kidney-shaped

concave articular facets are located on the superior surfaces of the lateral masses of the atlas. The occipital condyles rest in these facets to form the atlanto-occipital joints. It is by way of the atlanto-occipital joints that the weight of the head is transmitted to the spine. The atlanto-occipital joint is a gliding joint which permits independent flexion and extension of the head. There is no hinge motion in the atlanto-occipital joint. Instead, it is more like the motion of rockers on a rocking chair.

Notice that the occipital condyles rest in the articular facets of the atlas. When the head is in balance atop the spine, the muscles of the neck need to exert only minimal effort to hold the head up. (Neumann D. A., 2010) This translates into less tension not only in the neck but also in the back.

The atlas lacks a body, pedicles, lamina, and spinous process, as can be seen in Figure

6. It has rather robust transverse processes which serve as points of attachment for the levator scapulae muscles. Thus, each of the transverse processes of the atlas bears the loading of the scapula on its respective side. This is of practical significance to the clarinetist since any movement of the arms exerts a compressive force not only on the atlas but on the entire cervical spine. Thus, any tension in the shoulders and arms while playing the clarinet creates a downward pull on the spine.

Figure 5. The cervical spine, seen in lateral view. Note the prominent spinous process of the axis (C-2). Also note the absence of a spinous process of the atlas (C-1). The most inferior of the cervical vertebrae, C-7 is seen to resemble the thoracic vertebrae which lie directly inferior to it. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The axis, C-2, is designed to permit rotation of the head. It has a specialized osteologic feature, the dens, which extends through the atlas. The dens, which is also known as the odontoid process, is the vertical axis around which the head rotates.

Figure 6 shows the axis viewed from posteriorly and superiorly and demonstrates this unique feature. The atlanto-axial joint (the joint between the atlas and the axis) is responsible for around 50% of the rotation in the cervical region. (Neumann D. A.,

2017) The remainder occurs in C-3 through C-7, allowing the head about 120-130 degrees of rotation around the vertical axis. (Ibid.) The axis is also the strongest of the cervical vertebrae supporting the weight of the head which is transmitted to it from the atlas through its superior articular facets. In spite of the strength of this vertebra, the high degree of mobility in this region contributes to the propensity for injuries to occur here. (Oatis, 2009)

Figure 6. The atlas viewed from posteriorly (upper image) and from above (lower image).Note the kidney-shaped superior articular facets on the lateral masses (seen in dark gray on the upper image). It is in these concave structures that the occipital condyles rest. They receive the weight of the skull and transmit it to the remainder of the spine while allowing a rocking motion of the head. (3D4Medical Essential Anatomy 5 © 2018. Used with permission.)

The most mobile region of the entire spine is the craniocervical region. It is here that precise positioning of the head occurs. Head position is of significance to the clarinetist not only for establishing good lines of sight for music, conductor, and colleagues, but also for establishing a neutral, tension-free position for playing the clarinet. As has been described, the occipital condyles rest in the reciprocal superior facets of the atlas. When this relationship is in balance, the least amount of effort is expelled to support the head. (Neumann D. A., 2017)

Because the center of gravity of the head lies anterior to this point of balance, the head has a natural tendency to rotate forward which actually helps to lengthen the spine. (Dimon, 2008)

Figure 7. The axis as viewed from above (image on left) and from posteriorly (image on right). Note the superior articular facets, best seen in the superior view (in light gray). The dens, or odontoid process, is best seen in the lower image, projecting superiorly. This vertical axis permits rotation of the head. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

Figure 8. Posterior-superior view of the atlanto-axial relationship. The atlas is in green. 1. Posterior arch of atlas; 2. Vertebral canal for spinal cord; 3. Odontoid process; 4.Transverse foramen through which the vertebral artery passes. (Adapted from Hanson, Netter’s anatomy coloring book, Plate 2-A© 2010.)

Figure 9. When the head is balanced, as on the right, less muscular activity is necessary to maintain its position. When the head is placed forward of its natural balance point, as on the left, the curve of the cervical spine is distorted and muscles of the neck and back must work harder to maintain this imbalanced position.

Problems occur when the head moves too far forward. Forward head position is a common finding among clarinetists, (Rietveld, 2013) and will be discussed further in the chapter ‘Posture.’

Figure 10. An increased load is placed upon the neck as the head is moved forward. This may lead to increased cervical lordosis as seen in the radiograph on the left. This load is transmitted down the length of the spine. Chronic forward head position may lead to the eventual formation of a Dowager’s hump with associated loss of height and abnormal curvature of the spine. (© 2018, Erik Dalton, www.erikdalton.com Used with permission.)

The Thoracic Spine and Rib Cage

The thoracic spine with its kyphotic curvature is composed of 12 vertebrae. These vertebrae have wedge shaped bodies, thicker posteriorly than anteriorly. It is this wedging of the thoracic vertebrae that creates the kyphotic curve of this part of the spine. The ribs join the thoracic vertebrae by way of the costocorporeal and costotransverse joints where they are held in place by extremely strong ligaments.

(Neumann D. A., 2010) There are facets in the bodies of these vertebrae which articulate with the heads of the ribs. The bodies of T-2 through T-9 contain demi facets. These are located on the posterolateral borders of the both the superior and inferior sides of these vertebral bodies as shown in Figure 11. The heads of the second through ninth ribs thus articulate with two vertebrae, the inferior side of the vertebra above and the superior side of the vertebra below. T-1, T-10, T-11, and T-12 do not have demi facets. Instead, these vertebrae have full facets, and the heads of the corresponding ribs articulate only with the bodies of their respective vertebrae.

By way of the ribs, the thoracic spine is connected to the sternum to form the rib cage, as may be seen in Figure 12. Composed of the thoracic vertebrae, the ribs, and the sternum, the rib cage is comparatively rigid, allowing it to perform several important functions. First, it protects the heart and lungs located within it. Next, it provides a stable platform for the attachment of muscles necessary to position the skull and craniocervical region. It also creates the mechanical bellows necessary for breathing.

(Neumann D. A., 2010, p. 354)

These functions are in addition to transmitting and supporting the weight of the head, neck and upper body.

Figure 11. Superior and lateral views of thoracic vertebrae demonstrating the superior and inferior costal facets (demi facets), points of attachment for the heads of the ribs. The tubercles of the ribs articulate with the transverse costal facets. The ligaments securing the ribs to the thoracic vertebrae are extremely strong. (© 2017, Neumann, Kinesiology of the Musculoskeletal System, Elsevier, pg. 366.)

Corresponding to the twelve thoracic vertebrae, there are also twelve pair of ribs. The top seven ribs attach directly to the sternum and are sometimes referred to as “true ribs.” The eighth, ninth, and tenth ribs are connected to each other and indirectly to the sternum by cartilage forming the costal arch. (Figure 13) Because they do not attach directly to the sternum, these three ribs are known as “false ribs.” The last two ribs, the eleventh and twelfth, are called “floating ribs” because they lack any anterior points of bony attachment. (Dimon, 2011) Although the rib cage is comparatively rigid, it also exhibits flexibility necessary for respiration. The costal cartilages play a major role in lending elasticity to the rib cage.

Figure 12. The thoracic spine (highlighted in green). The ribs attach to the vertebrae posteriorly and to the sternum anteriorly to form the rib cage. The attachment to the sternum is via the costochondral cartilages which do not appear in these illustrations. In the lateral view (left) the overlying bony structures have been faded to allow the curvature of the spine to be visualized more clearly. (3D4Medical Essential Anatomy 5© 2018. Used with permission.)

Figure 13. The twelve ribs on the left side of the body are highlighted in green in the illustration on the left. It can be seen that the ribs do not extend all the way to the sternum. The costal cartilage has been added in the illustration on the right and is highlighted in light green. Here it can be seen that the “false ribs” are attached to each other by cartilage and only indirectly to the sternum. The floating ribs lack anterior attachment. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The Lumbar Spine

The five lumbar vertebrae are characterized by their massive bodies. Their total mass is roughly double that of all seven cervical vertebrae taken together. (Neumann D. A.,

2010) It is upon the bodies of these vertebrae that the weight of the upper body—the head, trunk, and upper extremities—is supported and transmitted to the sacrum and pelvis.

Figure 14. The lumbar spine. The illustration demonstrates the five lumbar vertebrae in their anatomic orientation. Note the lordotic curve (convexity toward the front of the body). (3D4Medical Essential Anatomy 5 © 2018. Used with permission.)

The resting lordotic curvature of the lumbar spine (Figure 14) may be altered by changing the tilt of the pelvis. When tilted posteriorly, the lumbar lordosis is reduced.

Conversely, when the pelvis is tilted anteriorly, the lumbar lordosis is exaggerated.

(Neumann D. A., 2010) A markedly exaggerated lumbar lordosis may produce a number of negative effects. Increased compressive pressure may occur posteriorly between the lumbar vertebrae. In addition, an exaggerated lumbar lordosis causes an increased anterior shearing force in the lower lumbar spine and lumbosacral junction.

This condition tends to cause the nucleus pulposis of the intervertebral disc to shift forward. In some individuals, an excessive lumbar lordosis may lead to anterior spondylolisthesis, a condition in which one vertebra slides forward on the vertebra below it. (Neumann D. A., 2017) An exaggerated lumbar lordosis may be seen in clarinetists who lean the upper body posteriorly at the waist while playing. (Figure 15)

Figure 15. An exaggerated lumbar lordosis is seen in a clarinet soloist. He also exhibits a forward head position.

When the pelvis is tilted posteriorly, lumbar lordosis is reduced. This flexion of the lumbar spine creates increased pressure and narrowing anteriorly between the lumbar vertebrae and/or at the lumbosacral joint. Over time, this may deform the nucleus pulposis of the intervertebral disc, displacing it posteriorly. If the remainder of the disc, the annulus pulposis, is healthy, this may be of no consequence. If the disc exhibits weakness posteriorly, however, such as a cracked or distended annulus, the nucleus pulposis may ooze posteriorly where it may impinge upon the nerve roots or cord, a condition commonly known as a herniated or prolapsed disc. (Figure 17)

Symptoms of a prolapsed disc depend upon the specific nerve root which is impinged.

Pain, muscle weakness, changes in sensation, and decreased reflexes in the lower extremity may be experienced by the patient with this condition.

Figure 17. A herniated disc. This condition may be associated with an anterior pelvic tilt with its associated decrease in lumbar lordosis as is depicted in Figure 15. The MRI image below depicts a normal disc, a disc in a degenerative state, and a herniated disc. (©2018. Used under license with dreamstime.com)

The Sacrum and Coccyx

In the adult, the sacrum consists of five fused vertebral segments. This means that the sacrum functions as one large bone, leading to its other name, vertebra magnum.

Fusion begins at roughly five years of age and continues into the twenties. (Christian,

2009) Shaped like a triangle, the widest part of the sacrum, S-1, is oriented superiorly where it articulates with the inferior surface of the fifth lumbar vertebra. The resultant lumbosacral junction bears more stress than any other part of the spine. (Christian,

2009) Fortunately, the lumbosacral junction is reinforced by numerous ligamentous and muscular structures. (Ibid.) The lateral aspects of the sacrum have an articular surface which articulates with the iliac bones to form the sacroiliac joints. The concave ventral surface of the sacrum forms part of the posterior pelvic wall, as seen in Figure 18. Inferiorly, sacrococcygeal junction is formed by the articulation of the sacrum with the coccyx.

The coccyx is a vestigial remnant of the skeleton of the tail. (Dimon, 2011) Its name derives from the Greek word, kokkyx, meaning cuckoo, probably because of its beaklike structure. (Christian, 2009) Usually this bone is composed of four vertebrae which fuse in early adulthood. (Ibid.) Although not involved in weight bearing, a number of muscles and ligaments attach here. The tip of the coccyx is palpable in the intergluteal cleft where it is anchored to the overlying skin. (Ibid.) Because very little soft tissue overlies this bone, the coccyx is susceptible to trauma and contusion or fracture which can be quite painful, a condition known as coccygodynia. Such pain may also be experienced by thin persons who lack adequate gluteal mass if they sit for protracted periods. (Ibid.)

Figure 18. The sacrum as seen posteriorly (left) and anteriorly (right). Its anterior surface forms part of the posterior pelvic wall. Its lateral surfaces articulate with the iliac bones. Superiorly, the sacrum articulates with the lowest lumbar vertebra, L-5, to create the lumbosacral junction. Inferiorly, the sacrum articulates with the coccyx. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

Figure 19. The coccyx is seen on the left from anteriorly. Overlying and adjacent structures have been faded to allow better visualization. The coccyx is seen from posteriorly on the right. It is here that the bone is affixed to the overlying skin. Trauma to this area may result in contusion or even fracture. The coccyx is a vestigial remnant of the skeleton of the tail. (Dimon, 2011) (3D4Medical Essential Anatomy 5, © 2018. Used with permission .)

The Skull

The skull is comprised of twenty-two bones—eight cranial bones and fourteen facial skeleton bones. Figure 20 illustrates the relationships of these bones. The neurocranium, commonly referred to as the cranium, functions to house and protect the brain. It is formed by the occipital bone, two temporal bones, two parietal bones, the sphenoid, ethmoid, and frontal bones (Hollinshead, 1982). It can be thought of as consisting of the calvarium and skull base. (Figure 21) By adulthood, these bones are tightly fused together by joints known as sutures. The sutures allow no movement between the bones of the cranium. While the calvarium is a solid structure, the skull base contains several foramina through which important vascular and neural structures pass.

In addition to providing protection for the brain, the skull also houses and protects other important structures. The eyes are situated in the orbits. Sometimes referred to as the eye sockets, the orbits are formed by seven bones: the frontal bone, the sphenoid, the maxillary bone, the ethmoid, the zygomatic bone, the palatine bone, and the lacrimal bone. Together, these bones form a pyramidal shaped socket in which the eye and the muscles that move it reside. In the orbits, the eyes are well insulated from trauma from all directions except anteriorly.

The middle and inner ears are located within the temporal bones. The middle ear is an air filled space which communicates with the nasopharynx by way of the Eustachian tube.

The malleus, incus, and stapes, the three tiny bones responsible for transmitting sound energy from the eardrum to the cochlea, are found in the middle ear. The inner ear consists of the cochlea and labyrinth, sensory organs of hearing and balance, respectively.

These delicate organs are located in the petrous portion of the temporal bone. Deriving its name from the Latin word, petrosis, meaning stone-like, or hard, (Petrous part of the temporal bone, 2017) the petrous bone is the densest bone in the body.

The olfactory bulb, the organ responsible for the sense of smell, sits in the middle cranial fossa atop the cribiform plate of the ethmoid bone. The actual olfactory nerve fibers originate in the mucous membrane in the upper third of the nasal cavity. These delicate fibers pass through the cribiform plate and enter into the inferior portion of the olfactory bulb. Interestingly, the number of olfactory nerve fibers begins to decrease shortly after birth and continues to do so throughout life at a rate of about

1% per year. (Hollinshead, 1982) Although aging is a contributory factor, this loss of

olfactory fibers is thought to be due primarily to pathological changes within the nasal mucosa. (Ibid.)

The atlanto-occipital joint was introduced in the discussion of the craniocervical region of the cervical spine. The base of the skull is seen in Figure 21 with all structures faded except the occipital bone. The occipital condyles are highlighted in green. These convex structures rest in the reciprocally concave facets of the atlas (C-1), a design lending stability to the joint. The motion here is similar to that of a rocking chair on its rockers allowing the head to nod. There is essentially no other movement at this joint.

The atlanto-occipital joint is located more anteriorly and superiorly in the head than many people may realize. Its anatomical location is seen in Figure 22.

The paired maxillary bones are structures of importance to the clarinetist. The right maxilla is shown in Figure 23 in lateral view. As may be seen, the maxillary dentition

(upper teeth) is rooted here. The two central maxillary incisors rest atop the clarinet mouthpiece. A mouthpiece patch of thin silicone or similar material is often placed atop the mouthpiece to prevent the central incisors from sliding on it. Notice that the palatal processes of the two maxillary bones come together at the midline to form the anterior portion of the hard palate. The nasal cavity and maxillary sinuses lie above the hard palate. The face of the maxilla above the teeth forms the anterior wall of the maxillary sinus. It is easy to imagine how dental issues such as decay, abscess, or gingivitis could impact the performance of the clarinetist. Infection in the maxillary sinus (Figure 24) may present with a variety of symptoms including but not limited to pain in the maxillary teeth as well as headache and pressure in the face. Maxillary sinusitis is an unpleasant condition for anyone. For clarinetists who must blow against resistance, maintain a firm embouchure, and hold pressure against the mouthpiece

with the maxillary central incisors, a sinus infection can be miserable. Untreated sinusitis can lead to chronic sinusitis as well as other serious complications.

Figure 21. The occipital bone is shown in the illustration on the left. The convex occipital condyles are highlighted in green. The large hole between the condyles is the foramen magnum through which the spinal cord travels. The atlas is depicted in the image on the right.. Its concave facets are highlighted in grey. It is in these facets that the occipital condyles rest. This joint permits the skull to rock much like the motion of the rockers on a rocking chair. (3D4Medical Essential Anatomy 5 © 2108. Used with permission.)

Figure 22. The atlanto-axial joint. Overlying structures have been faded to allow visualization of the AO joint. A common misconception is that this joint is located much lower than it really is. As can be seen, this joint is located higher than the angle of the mandible, at about the level of the external auditory canal. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The maxillary sinuses are not the only air filled cavities in the head. There are also sinuses in the ethmoid and the sphenoid bones. Along with the maxillary sinuses, these are collectively referred to as the paranasal sinuses. Any or all of these sinuses may become infected and lead to symptoms and possible complications. The paranasal sinuses do function in capacities other than serving as repositories of infection. Because they are filled with air, they decrease the weight of the head, thus reducing the load on the spine. In addition, they act as a sort of crumple zone in the head helping to protect the brain from trauma.

Figure 23. The right maxilla is seen in lateral view (highlighted in green) in the illustration on the left. The middle illustration views the left maxilla from inferiorly. The anterior portion of the hard palate is formed by the fusion of the maxillae in the midline. In the frontal view, seen on the right, the left central incisor is highlighted in green. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

Figure 24. CT scans of the maxillary sinuses. Note that radiologic images are viewed as if one is standing in front of the patient; thus, the patient’s right side is on the viewer’s left and vice versa. On CT scan, bone appears white while air is seen as black. Normal sinuses are air filled. The image on the top is an axial CT scan. The red arrows point to the maxillary sinuses. The lower image is a coronal CT scan revealing right maxillary sinusitis. In the maxillary sinus on the left there is clear delineation between the bone (white) and air (black) which indicates a normal sinus. On the right however, the thick irregular areas in gray demonstrate mucosal thickening within the sinus, typical of chronic sinusitis. (Harsha Yadav © 2014. Used with permission)

The Mandible

The mandible, or jawbone, (Figure 25) is not an integral part of the skull but rather articulates with it by way of the temporomandibular joint (TMJ) and utilizes the skull as the platform from which its motion occurs. In this sense, it functions like an appendage of the skull. It does add weight to the anterior skull, thus shifting the center of gravity of the head slightly forward of AO joint which actually results in a

lengthening of the spine. The mandibular dentition is basically a mirror image of the maxillary teeth situated above them. In the clarinet embouchure, the lower lip acts as a cushion between the central and lateral incisors and the reed. Some clarinetists utilize a cover over the central and lateral incisors in order to protect the mucosal surface inside the lower lip from trauma while playing. A variety of materials have been used for this purpose including pieces of thin rubber, cardboard, denture lining material, and paper to name a few. If the chewing surfaces of these teeth are irregular or sharp, such a strategy is helpful. A dentist can easily fashion a custom appliance to help protect the lip. If the teeth are regular in shape and comparatively smooth, a lip protector is probably unnecessary under normal conditions, and persistent trauma to the lower lip may be a sign that the clarinetist is playing with too much pressure from the jaw. If the length of time playing the instrument is drastically increased as might happen during a music festival or band camp, it may be helpful to cover the lower central and lateral incisors.

The condylar process of the mandible articulates with the mandibular fossa in the temporal bone. The joint formed by these two bones and the intervening cartilaginous disc is the temporomandibular joint (TMJ). The TMJ is both a hinge and gliding joint which allows jaw opening and protraction to occur simultaneously. (Hollinshead,

1982) This arrangement permits the mandibular movements necessary for chewing, the formation of sounds necessary for speech, and creating a secure embouchure for playing the clarinet. The forces exerted on the TMJ are huge. In the adult, peak bite force on the molars may reach 225 lb. (1000 N). (Oatis, 2009) Assuming a molar bite force of 112 lb. (500N), it has been calculated that the force exerted on the head of the condyle is 197 lb. (877 N). (Ibid.) Incisor bites can also be quite forceful, with loads ranging from 34 to 90 lbs. (150 to nearly 400 N). During chewing, the TMJ on the

balancing (non-chewing) side actually sustains roughly twice the load of the chewing side. (Ibid.) This asymmetrical force occurs because the mandible tilts toward the balancing side during chewing. Foods that are more difficult to chew cause greater compression on the non-chewing side. (Oatis, 2009)

The TMJ may become the source of a variety of clinical symptoms collectively known as temporomandibular disorders (TMD). (Neuman, 2010) Sometimes referred to as TMJ, the symptoms are widely variable but may include headaches, clicking or popping in the joint, tinnitus, decreased mandibular range of motion, tenderness of the muscles of mastication and craniocervical muscles, and referred pain. (Ibid.) Factors associated with the development of TMD include grinding of the teeth (bruxism), psychological stress, and chronic forward head posturing. (Ibid ) It is recommended that patients with TMD symptoms receive complete evaluations of their posture.

(Iglarsh & Oatis, 2004) Treatment is generally conservative.

The Hyoid

A small horseshoe shaped bone in the anterior neck at the level of the third cervical vertebra, the hyoid bone does not articulate with any other bone. (Figure 26) It is held in place by the muscles that attach to it but remains mobile to participate in actions such as swallowing, speaking, and moving the tongue. (Neuman, 2010). The muscles attached to the hyoid are generally grouped by whether they attach on the superior or the inferior surface of the bone. The infrahyoid muscles are the sternohyoid, omohyoid, and thyrohyoid muscles. The middle pharyngeal constrictor attaches laterally, and the stylohyoid, digastric, mylohyoid, geniohyoid, and genioglossis all attach to the superior surface of the hyoid. (Hollinshead, 1982) These muscles will be discussed in Chapter II, The Muscles.

Figure 25. The mandible and its parts. In the illustration on the left, the mandible is highlighted in green while other surrounding structures have been faded. It is shown in its anatomic location. Parts of the mandible are shown on the right alveolar ridge, light green; body of mandible, pale yellow; ramus of mandible, pale blue; yellow strip above ramus, neck of condyle; condyle is bone colored rounded projection atop neck of condyle; coronoid process is gray horn-shaped projection atop ramus. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The Upper Extremities

Every clarinetist recognizes the importance of the hands and fingers. In reality, however, the entire upper extremity is involved with holding and playing the instrument. The discussion of the skeletal system will continue with the bones and joints of the shoulders, arms, and hands.

The Shoulder Complex

The shoulder complex is comprised of a set of articulations involving the sternum, clavicle, ribs, scapula, and humerus as is demonstrated in Figure 27. The sternum is a part of the rib cage, making it a component of the axial skeleton. It also functions as an important part of the shoulder complex as the point from which the entire upper extremity is suspended from the axial skeleton. The first through seventh ribs attach directly to the sternum by way of the costal cartilages while the eighth, ninth, and tenth ribs share an indirect cartilaginous connection with it.

When viewed from above (Figure 28), the clavicle has an appearance similar to the handle of a crank. (Oatis, 2009) It functions as a mechanical strut by which the upper extremity is attached to the rib cage, and thus to the axial skeleton. (Oatis, 2009)

Medially, it articulates with the clavicular facets on the sternum and also rests against the cartilage of the first rib. (Neumann D. , 2010) The sternocostal joint thus formed allows the acromion of the scapula to form the acromioclavicular joint. (Ibid.) This creates a direct link between the shoulder and the sternum. In the earlier discussion of the cervical spine, it was seen that movement and tension of the arms exerts a compressive force on the spine.(Ibid.) Now it may be seen that movement and tension in the arms and shoulders may also exert forces upon the rib cage.

Figure 26. The hyoid bone, highlighted in green, is shown in its anatomic position in the image on the left. Other structures have been faded to allow visualization of the hyoid. The image on the right demonstrates the hyoid as seen from above. The yellow portion is the body. The gray portions are the greater cornu. The barely visible green protrusions surrounded by a stippled circle are the lesser cornu. (3D4Medical Essential Anatomy 5 App, © 2018. Used with permission)

Figure 27. Components of the right shoulder complex viewed from anteriorly (left),posteriorly (middle), and laterally (right). The scapula and clavicle are highlighted in green. The sternum is gray. The articulation of the clavicle with the sternum is the only point of bony attachment with the axial skeleton for the entire upper limb. (3D4Medical Essential Anatomy 5, © Used with permission.)

The scapula is a rather large roughly triangular shaped bone with the base of the triangle at the top. At rest it generally lies between the second and seventh ribs. The shallow glenoid fossa on its lateral aspect is the site of articulation with the head of the humerus. The resultant glenohumeral joint is designed more for mobility than stability. (Dimon, 2011) The acromion acts as a protective roof over the head of the humerus. (Oatis, 2009) The scapula at rest lies upon the posterolateral surface of the thorax where it forms the scapulothoracic joint. This is not a joint in the traditional sense of bone articulating with bone. (Neumann D. , 2010) The scapulothoracic joint is the point of contact between the scapula and the posterolateral wall of the thorax where the two are actually separated by a number of muscles including the subscapularis, the serratus anterior, and the erector spinae. The slick surfaces of these muscles permit the scapula to glide over the thorax during movement. The large

movements at the scapulothoracic joint play a major role in the range of motion of the shoulder. (Ibid.) A total of seventeen muscles attach to the scapula. (daniel, 2011) As will be seen, the shoulder is a “floating” structure with the muscles attaching to it serving multiple functions. (Dimon, 2011) Figure 29 demonstrates the surfaces of the right scapula.

Figure 28. The right clavicle, highlighted in green, as viewed from above. Its articulation with the clavicular facet atop the sternum is seen on the right and its articulation with the scapula at the acromioclavicular joint is visible on the left. Note the crank handle shape of the clavicle. As a result of this shape, the acromoclavicular joint lies approximately 20 degrees posterior to the frontal plane when the shoulder is in a relaxed anatomical position. ( 3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

Figure 29. The right scapula is a roughly triangular shaped bone as is seen in the anterior (left) and posterior (right) views above. The red tip of the triangle seen medially is the superior angle. The large area in gold on the anterior view is the subscapular fossa; the orange surface seen on the left side of the anterior view is the lateral border, and the superior border is shown by the orange line seen superiorly as it crosses the coronoid process and continues along the top of the trianglular body The acromion is the hook shaped process protruding superiorly and laterally. The small red tip seen on both views is the superior angle. On the posterior view, orange structure which begins medially and terminates laterally into the acromion is the spine of the scapula. Above the spine lies the supraspinous fossa, in gold. The infraspinous fossa is shown in yellow below the spine. The articular surface of the glenoid is the smooth oval structure in light gray seen on the anterior view. ( 3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The head of the humerus is about 2 ½ times larger than the glenoid fossa with which it articulates. It is inaccurate to think of it as a ball-in-socket joint. It’s actually more like a “golf ball pressed against a coin the size of a quarter.” (Neumann D. , 2010)

The stability of the glenohumeral joint is due to a combination of both passive tension

from ligaments and dynamic forces produced by the four muscles of the rotator cuff, the supraspinatus, the infraspinatus, the teres minor, the subscapularis and their tendons. (Watson, 2009) Thus the shoulder complex consists of the sternum, clavicle, scapula, ribs, and humerus; the four joints that interrelate them (the sternoclavicular, the acromioclavicular, the scapulothoracic, and the glenohumeral); and the muscles, tendons, and ligaments that hold everything together.

The single bone of the upper arm is the humerus. (Figure 30) Its head forms part of the shoulder complex and its shaft provides sites for the attachment of a number of muscles. Its distal end widens to form the trochlea and medial epicondyle on its medial aspect, and the capitulum and lateral epicondyle on its lateral aspect. It is here that the bones of the forearm, the radius and ulna, articulate to form the elbow joint.

The olecranon process on the proximal end of the ulna is the bone felt as the point of the elbow. The proximal end of the ulna contains the trochlear notch which resembles the jaw of a crescent wrench and articulates with the trochlea on the lateral aspect of the humerus. There is also a radial notch in the proximal ulna which articulates with the disc like radial head (Neumann D. A., 2017).

Figure 30. A posterior view of the right humerus is highlighted in green. The scapula and clavicle above and the radius and ulna below have been faded. Notice how the humerus widens distally. The projection of the medial epicondyle is clearly visible. ( 3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The elbow and shoulder joints are a study in contrasts. The shoulder is the most mobile joint in the body. The shape of the glenohumeral joint affords this joint great mobility at the expense of stability. (Dimon, 2008) The muscles of the shoulder provide most of the stability of the glenohumeral joint. There are ligaments at the shoulder joint but they provide support only at the extreme ranges of motion. The elbow, however relies upon articular joints that fit tightly together as well as collateral ligaments which provide not only stability but also help limit the motion of the elbow in extension. (Neumann D. A., 2017)

Figure 31. In the image on the left, the right ulna is shown in isolation in medial view demonstrating the trochlear notch. The shape of the trochear notch resembles the jaw of a crescent wrench and fits snugly onto the trochlea of the humerus. This arrangement, along with the collateral ligaments , provides the elbow with great stability but restricts this joint’s range of motion. The ulna, highlighted in green, is shown in its anatomic position in the image on the right. Overlying structures have been faded. ( 3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The muscles of the elbow play only a minor role in its stabilization. These muscles function primarily to create movement at the elbow. Both joints play a significant supportive role for the clarinetist. It has been calculated that the elbow sustains a compressive load of nearly 1.2 times the body weight when a load of five pounds is held with the elbow flexed. (Neumann D. A., 2017) Even though the clarinet weighs only about two pounds, it places a compressive load on the flexed elbow of nearly

50% of the body weight! This is actually slightly greater than the peak compressive force of 45% of the body weight sustained by the elbow during a push-up. (Ibid.)

Figure 32. The ligaments of the right elbow are highlighted in green in the image on the left. The ligaments of the right shoulder are highlighted in green in the image on the right. The ligaments of the elbow are tightly applied to the bones creating a stable joint. In the image on the right, it can be seen that the bones of the shoulder are not as tightly bound as those of the elbow. This laxity is responsible in part for the fact that the shoulder is the most mobile joint in the body. It also causes the shoulder joint to be comparatively unstable. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The radius is capable of movement relative to the ulna by virtue of the proximal and distal radioulnar joints. It is this movement that results in supination (palm up) and pronation (palm down) of the forearm and hand. These joints move independently of the ulnohumeral joint meaning that the elbow can remain fixed while the forearm

rotates. In supination, the radius and ulna are in an essentially parallel relationship. As the forearm begins rotation, the radius begins its rotation relative to the ulna. The radial head is disc shaped and articulates with the radial facet on the ulna forming the proximal radioulnar joint (PRUJ). The axis of forearm rotation passes through the center of the radial head proximally and through the ulnar head distally. (Matsuki, et al., 2010) A thick circular band of connective tissue, the annular ligament, surrounds the radial head and attaches to the ulna on either side of the radial notch. The rotational movement of the radius at the PRUJ occurs within this annular ligament. As the PRUJ rotates, the distal radius rotates upon the distal ulna at the distal radioulnar joint (DRUJ) causing the radius to actually cross over the ulna. In pronation, the distal head of the ulna is situated laterally while the distal radius assumes a medial position.

(Figure 33) The forearm rotation is actually more complex than the rotation of the radius on the ulna. There is also a limited amount of gliding motion or translation involved. In addition, the concave fovea atop the head of the radius spins on the capitulum of the humerus. (Oatis, 2009)

The interosseous membrane joins the radius and ulna through the length of the forearm. This is actually stout connective tissue with its fibers oriented so that loads to the distal radius may be distributed to the ulna. (Neumann D. A., 2017) Since the forearm is a part of the kinematic chain extending from the craniocervical region to the fingers of the hand (Mofatt & Vickery, 1999), its function is extremely important to the clarinetist.

The Wrist and Hand

The hand and wrist are capable of an amazing array of precision movements, as any clarinetist can attest. One reason for this versatility is the skeletal anatomy of these

structures. Roughly half of the bones in the human body reside in the hands and wrists. Each hand contains 27 bones with joints that permit them to move in concert with or independently of each other as the situation requires. (Oatis, 2009) Hand function is greatly influenced by position and stability of the wrist. (Neumann D. A.,

2017)

Figure 33. The bones of the forearm. In the illustration on the left, the radius and ulna are parallel. The hand and wrist would be in supination. In the illustration on the right, the radius has rotated over the ulna which would bring the hand and wrist into pronation. (© 2018 Elsevier Inc. All rights reserved. www.netterimages.com Used with permission.)

The distal articular surface of the radius contains two concavities which constitute the proximal articular surface of the wrist. (Ibid.) The radius is the principal player in forearm rotation, but it also has a major role in flexion and extension of the wrist.

(Neumann D. A., 2017) Its distal end is angled which allows for more flexion than extension at the wrist. It also permits the hand greater ulnar deviation than radial deviation. (Ibid.) The convex proximal heads of the scaphoid and lunate bones articulate with the distal radius.

The eight bones of the wrist, or carpals, are arranged in two rows and form the link between the forearm and the hand. They are small, each roughly the size of a sugar cube. (Meals, 2008) In aggregate, these bones are sometimes referred to as the carpus,

and they function to provide both stability and flexibility to the hand. The proximal row, from radial to ulnar, includes the scaphoid, lunate, triquetrum, and pisiform. The distal row includes the trapezium, trapezoid, capitate, and hamate. The proximal carpals are rather loosely bound, consistent with their role in wrist movement. The distal row, however, is much more tightly approximated providing a stable site for the attachment of the metacarpals. (Ibid.) Collectively the carpal bones form an arch, concave on the palmar aspect. The flexor retinaculum, or transverse carpal ligament, crates a roof on this concavity to create the carpal tunnel. (Oatis, 2009)

The scaphoid bone articulates with radius and the capitate via rounded surfaces which permit a great deal of mobility. It also articulates with the lunate, trapezium and trapezoid, but these joints are limited in their mobility allowing only some sliding or translational movement. (Ibid.) Medial to the scaphoid is the lunate, the central bone of the proximal row. Due to its shape and lack of strong ligamentous and muscular attachments, it is the most unstable of the carpal bones. (Neumann D. A., 2017) While the distal radius has the distinction of being the most commonly fractured bone in the upper extremity, the scaphoid and lunate rank second and third respectively. (Ibid.)

They are positioned between the distal forearm and the distal row of carpal bones, both of which are rigid structures making them vulnerable to compression injuries.

Neumann describes the scaphoid and lunate as being , “Like a nut within a nutcracker…” (Ibid.) The triquetrum has the most ulnar position of all of the carpal bones and is easily palpable on the ulnar side of the wrist during radial deviation. Its articulation with the hamate allows significant movement. (Oatis, 2009) The pisiform loosely articulates with the palmar side of the triquetrum. This small pea shaped bone is embedded within the tendon of the flexor carpi ulnaris (Neumann D. A., 2017)

where it adds to the mechanical advantage of that muscle. (Oatis, 2009) Several other ligaments attach to the pisiform including the flexor retinaculum.

Figure 35. The proximal row of carpal bones of the right wrist viewed from anteriorly. Above, left, scaphoid; right, lunate; below, left, triquitrum; right, pisiform. These bones are highlighted in green. (3D4Medical Essential Anatomy 5, © 2018. Used with permission)

The trapezius occupies the most radial position of the distal row of carpals. Its saddle- shaped distal end articulates with the proximal end of the metacarpal of the thumb.

This highly specialized articulation allows the thumb a wide range of motion.

(Neumann D. A., 2017) It is noteworthy that the trapezius articulates with the anterior surface of the scaphoid which places it out of the plane of the other carpals. This position places the thumb anterior to the palm at a roughly 45⁰ angle with the index finger, an arrangement that facilitates pinching movements. (Oatis, 2009) The joint of the trapezium with the first metacarpal allows the thumb to move across the palm toward and interact with flexed fingers. Such movement is necessary for nearly all prehensile movements. (Neumann D. A., 2017) It also facilitates many of the movements of the hand necessary to play the clarinet.

The trapezius is one of the four “pillars” of the carpus to which the transverse carpal ligament (flexor retinaculum) attaches. The trapezoid lies adjacent to the trapezius wedged between it and the capitate. The primary function of the trapezoid is to

provide a stable base for the metacarpal of the index finger, a function of critical importance when the index finger is called upon to perform a powerful pinch. (Oatis,

2009)

The largest of the carpal bones is the capitate which occupies a central location within the wrist. It acts as a keystone of the carpal arch, (Ibid.) articulating with seven other bones within the hand. Its distal surface articulates with the third metacarpal.

Together, the capitate and the third metacarpal function as a stable central column which makes a significant contribution to the stability of the hand and wrist.

(Neumann D. A., 2017) The axes for all rotational wrist motions pass through the capitate. (Ibid.)

Named for its hooklike projection, its hamulus, the hamate bone articulates distally with the bases of the fourth and fifth metacarpals. Here, it lends mobility to the ulnar aspect of the hand, especially when the hand is cupped. (Ibid.) The hamulus of the hamate is one of the four pillars to which the transverse carpal ligament attaches.

(Oatis, 2009)

Figure 36. The distal row of carpal bones in the right wrist. Highlighted in green, from radial (left) to ulnar (right): trapezium; trapezoid; capitate; and hamate. (3D4Medical Essential Anatomy 5, © 2018.) Used with permission)

The metacarpals look much like miniature versions of the humerus or femur. The metacarpal of the thumb articulates proximally with the trapezium and distally with the second phalanx of the thumb. This joint is subjected to wear and tear in clarinetists.

The weight of the clarinet is supported on the right thumb which acts as a lever that transmits a compressive force several times that of the weight of the clarinet to the joint of the first metacarpal and the trapezium. (Hoppman, 2010) Osteoarthritis in the carpometacarpal joint of the thumb is a common cause of pain in the thumb. (Ibid.)

Figure 37. The first metacarpal is highlighted in green. It articulates proximally with the trapezium by way of a saddle shaped joint which allows great mobility for the thumb. This bone also acts as a lever which magnifies compressive forces at this joint. Since the clarinettist supports the weight of the clarinet on the distal thumb, a considerable amount of compressive force is imposed upon this joint. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The second, third, fourth, and fifth metacarpals span the distance from the carpals to their corresponding digits and are arranged in a roughly parallel alignment. All metacarpals share a similar design consisting of a base, shaft, and head. The bases articulate proximally with one or more of the carpals. A shaft extends distally from

each of the bases and terminates distally in a large convex head. (Neumann D. A.,

2017) These heads are easily recognizable as the knuckles when the hand is made into a fist. The shafts of the metacarpals exhibit a longitudinal concavity toward the palm which creates room for the intrinsic muscles of the hand and the numerous tendons passing through this area.

The phalanges are the bones of the fingers. Each hand has fourteen phalanges, three in each finger and two in the thumb. The joints between the phalanges are simple hinge joints, but the tendons and connective tissue that operate these hinges is far from simple. These structures will be discussed in greater detail in Part II, The Muscular

System.

Figure 38. The third metacarpal is highlighted in green. Note the convex rounded head which articulates with the proximal phalanx of the third digit. The metacarpal heads are easily visualized as the knuckles when the hand is made into a fist. The longitudinal concavity on the palmer aspect of the metacarpals is apparent. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The Pelvis

The bony pelvis functions to transmit the weight of the upper body to the lower limbs.

In addition, it supports the pelvic organs, the muscles of the pelvic floor, and is the site of attachment for a number of trunk and leg muscles. (Corton, 2005) It is comprised of the ilium, ischium, pubic bones, sacrum, and coccyx. The ilium, ischium, and pubis are fused at puberty to form a Y-shaped joint known as the cup of the acetabulum, the socket for the femoral head. In aggregate these three bones are sometimes referred to simply as the “hip bone,” and when the femoral head is included, it creates the hip joint. The sacrum has already been described as part of the spine, but it also forms a significant portion of the pelvis, comprising most of the posterior part. The coccyx plays no significant role in the pelvic structure. In the very thin clarinetist who is required to sit for protracted periods of time, the coccyx may become a source of annoying pain.

The pelvis is an extremely important structure to the clarinetist because of the significant role that it plays in posture and support. In addition to its function in transferring weight from the upper body, many muscles from the trunk and legs attach to the pelvis as do numerous ligamentous structures. These muscles and connective tissue combine to form the floor of the pelvis, which in combination with the bony pelvis, supports and protects the bladder, reproductive organs, and bowel. (Neumann

D. A., 2017) Much of the clarinetist’s playing is done in the sitting position, and it is in this position that the ischial tuberosities become the primary weight bearing structures. One might envision the ischial tuberosities as the feet of a penguin, (Kind, n.d.) providing the base of support for the head, arms, and trunk above when seated.

The pelvis is able to tilt both posteriorly and anteriorly. Because the sacrum is a portion of the spine, it is easy to see that any change of angle here will also result in

changes of the curvature of the spine above. The pelvis may also tilt in the standing position and here, too, changes are transmitted to the spine above.

Figure 39. The ilium (left), ischium (middle), and pubis (right) are highlighted in green. They become tightly fused at puberty to form the socket for the head of the femur, the acetabulum. (3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The sacroiliac joint between the articular surfaces of the sacrum and iliac bones is an atypical synovial joint in that it allows essentially no movement, even though hyaline cartilage and a synovial membrane lined joint cavity are present. This joint is designed primarily for transfer of weight. (Corton, 2005) If this joint capsule is reduced in size, as may occur with advancing age or as a result of prior trauma, lower back pain or sciatica may ensue. Anteriorly, the two halves of the pelvis are united at the pubic symphysis by a disc of fibrocartilage much like the intervertebral discs located between the vertebral bodies. Usually this joint allows for very limited movement, up to 2 mm of translation and minimal rotation, (Neumann D. A., 2017) but during pregnancy the cartilage of the symphysis pubis softens due to hormonal influences to allow for pelvic expansion during childbirth. (Corton, 2005)

Figure 40. The pelvis is shown with the cartilaginous disc of the pubic symphysis highlighted in green. This cartilage softens in response to hormones of pregnancy to allow for pelvic expansion during childbirth. (3D4Medical Essential Anatomy 5. © 2018. Used with permission.)

The acetabulum is the socket into which the head of the femur fits to create a ball- and-socket joint. The proximal head of the femur is nearly spherical in shape and covered with articular cartilage. In contrast with the shoulder where stability is sacrificed for the sake of mobility, the hip joint is tightly bound with ligaments and favors stability and strength. The forces on the hip can reach 300% of bodyweight during the midstance phase of walking! (Neumann D. A., 2017) Fortunately the thick cartilaginous lining of the acetabulum and the surfaces of the femoral head are designed to withstand such loads. The centers of the femoral heads are only 6.9 inches

(17.6 cm) apart in the average adult. (Ibid.) While walking, the pelvis rotates in one direction while the lumbar spine simultaneously rotates in the opposite direction. The supralumbar trunk, head and neck remain relatively fixed while this is occurring, uninfluenced by the rotation of the pelvis. (Ibid.)

The neck of the femur angles inferiorly to join he shaft of the femur at an angle of around 120⁰ to form the longest bone of the body.(Ibid.) The femoral shaft is not straight but has a somewhat bowed configuration which helps to reduce the forces

delivered to the hip. In addition, the femur slants slightly medially as it descends. The distal femur widens to form two condyles which articulate with the tibial plateau to form the knee.

Figure 41. The right femur is highlighted in green. The medial inclination from the hip to the knee is readily apparent. The slight bowing is much more subtle. (3D4Medical Essential Anatomy 5, ©2018. Used with permission)

The tibiofemoral joint is the functional knee. The fibula and patella are not participants in movements of the knee. The condyles of the distal femur are large, rounded and convex while the tibial plateau is basically flat. Stability in the knee comes from muscles and ligaments rather than from the shape of the joint. (Ibid.) The patella is embedded in the tendon of the quadriceps. Its posterior surface is covered with cartilage which helps attenuate some of the compressive forces placed upon the joint.

The fibula acts as a sort of brace to the lateral side of the tibia helping to maintain its vertical position.(Ibid.) It transmits only a small portion of body weight to the foot.

The joints of the tibia, fibula, and talus are referred to as the ankle. The foot consists of the all of the bones distal to the ankle. The foot has three regions, the hindfoot, midfoot, and forefoot. (Ibid) The foot also has three arches. The medial longitudinal arch is the body’s primary shock absorber. Without this arch, it is doubtful that the bones of the foot could support the body’s weight. The transverse arch is located in the midfoot and functions to distribute weight over all five metatarsal heads. In addition, it provides transverse stability to the midfoot. The lateral longitudinal arch is much flatter than its medial counterpart, usually resting flat on the ground. (Little,

2017) Together these three arches form a tripod of support for the body of the clarinetist who is standing to play.

Chapter 3: The Muscular System

The human body is designed for movement, and muscles are the propulsion system for that movement. They are also of vital importance in supporting the body’s structure. It is beyond the scope of this document to provide a detailed description of all 700 muscles in the human body, but all of them are important. If a muscle exists, it is there for a reason. In this section groups of muscles of special significance to the clarinetist will be discussed. The origins, insertions and actions of these muscles and others are summarized in Appendix B.

Muscle Structure and Function

A skeletal muscle is composed of thousands of long slender fibers lying adjacent to each other and separated by delicate layers of connective tissue. Groups of fibers bundle together form fascicles which are also surrounded by connective tissue.

Fascicles then bundle together to form a muscle wrapped in a connective tissue sheath known as the epimysium. Thus, the entire muscle is enveloped in an organized system of connective tissue. (Oatis, 2009)

A muscle cell, or fiber, is long and multinucleated. Each fiber is composed of smaller units that are arranged parallel to the length of the fiber. The myofibril is the next smaller unit, composed of sarcomeres connected end to end for the length of the myofibril. The summation of the contractions of many sarcomeres is the engine which causes a muscle to contract. Sarcomeres contain myofilaments which are composed primarily of the proteins actin or myosin.

At rest, actin and myosin exhibit no affinity for each other. When a muscle is stimulated to contract, however, cross bridges form between the actin and myosin causing the actin to slide on the myosin. (Oatis, 2009) This shortens the lengths of the individual sarcomeres and results in contraction of the muscle. (Figure 45)

Figure 44. Myofilaments composed of either actin or myosin join together to form sarcomeres. Sarcomeres are the subunits of myofibrils. Groups of myofibrils in parallel arrangement group together to form long, multinucleated muscle fibers. These fibers in turn group with other fibers to form a fascicle. Bundles of fascicles are bound together to form a muscle. (Science Pics, © 2018. Dreamstime.com)

All of the various layers of connective tissue converge near the ends of the muscle to form tendons. Tendons on both ends of the muscle connect with the periosteum covering of bone and actually intermesh with collagen fibers within the bone.

(McArdle, 1996) This results in an exceptionally strong connection between the muscle and bone which is not easily disrupted. (Ibid.) The area where a tendon joins a

relatively stable part of the skeleton is called its origin. This region is generally the proximal or fixed part of a lever system (usually a long bone), or the area closest to the midline of the body. The distal point of attachment for a tendon is its insertion.

Figure 45. The sarcomere is the contractile unit of the muscle. Cross bridges between actin and myosin cause the actin to slide on the myosin thus shortening the length of the sarcomere. (Legger, © 2018. Dreamstime.com)

Muscles of the Embouchure

Many of the muscles used to create the clarinet embouchure are muscles of facial expression. All of the muscles of facial expression are innervated by the branches of cranial nerve VII (CN VII), the facial nerve. There are 21 pairs of muscles in the face.

While most of the body’s large muscles insert on bone, this group of muscles inserts on subcutaneous aponeuroses, skin, and/or mucosa. Over time, the pull of these muscles, in combination with the loss of skin elasticity, causes facial wrinkles.

Wrinkle formation is perpendicular to the direction of muscle contraction. (Oatis,

2009)

The primary muscle involved in the embouchure is the orbicularis oris. (Figure 46)

This muscle is generally depicted as a single muscle encircling the mouth, but the extent of actual sphincteric fibers is uncertain. (Hollinshead, 1982) From a functional standpoint, the orbicularis oris is thought to be two rather distinct muscles, the orbicularis oris superioris in the upper lip and the orbicularis oris inferioris in the lower lip. (White, 1974) It is known that fibers from other facial muscles intertwine with those of the orbicularis oris, while still others insert into it or pass through it to insert directly into the skin and mucosa of the mouth. (Hollinshead, 1982) Actions of the orbicularis oris include drawing the lips together, pulling the corners of the lips inward, puckering the lips, and drawing the lips inward against the teeth. (Ibid.) It has been referred to as the muscle of kissing and whistling. (Studyblue, 2018)

Other muscles acting upon the embouchure include the inferior muscle group, named for their location below the lower lip. This group is comprised of the depressor anguli oris, the depressor labii inferoris, and the mentalis. (Hollinshead, 1982) The upper group, lying above the upper lip, includes the risorius, the zygomaticus major, and

minor, the levator labii superioris, the levator superioris alaeque nasi, and the levator anguli oris. All of the aforementioned muscles are paired, but asymmetrical action by individual muscles within a pair is very common. (Oatis, 2009)

The depressor anguli oris pulls the corners of the mouth inferiorly and laterally.

(Hollinshead, 1982) Contraction of this muscle contributes to the classic frown.

(Oatis, 2009) Contraction of the depressor labii inferoris affects the lower lip, pulling it down and turning it outward. (Hollinshead, 1982) It is usually active in emotions of sadness or anger, helping to form a frown, but it can also be active in producing a wide smile in which the lower teeth are exposed. (Oatis, 2009) The lower lip is pulled upward and forward, as in a pouting expression by the contraction of the mentalis.

(Ibid.)

The zygomaticus major and minor pull the corners of the mouth laterally and superiorly toward the eyes. (Hollinshead, 1982) These muscles are usually referred to as the smile muscles because of their contribution to the production of a wide smile.

(Oatis, 2009) The zygomaticus muscles do not contract in isolation. (Ibid.) The rizorius usually contracts with them to assist in the production of a smile. If the rizorious is the primary muscle, it usually expresses emotions of dislike or disgust in the form of a grimace. (Ibid.) The two levators of the upper lip, the levator labii superioris and the levator labii superioris alaeque nasi, lift the upper lip and turn it outward. (Hollinshead, 1982) They contribute to the formation of the nasolabial crease which runs from the lateral aspect of the nostril to the corner of the mouth.

(Oatis, 2009) During a wide smile, these muscles help to retract the upper lip, but when contracted simultaneously with the procerus muscle, they produce an expression of revulsion or disgust. (Ibid.) The levator angularis oris lifts the lateral aspect of the

upper lip. In addition to helping produce a wide smile, many individuals are able to activate this muscle in isolation to produce a sneering expression. (Ibid.)

Figure 46. Muscles involved in formation of the clarinet embouchure. The buccinator, medial and lateral pterygoids lie deeper and are not seen in this illustration. (Adapted from 3D4Medical Essential Anatomy 5. © 2018. Used with permission.)

The buccinator is located deeper than any of the other facial muscles. It originates from the posterior surface of the maxillary alveolar process, the medial surface of the mandible at the junction of the body and the ramus, just posterior to the last molar, and from the pterygomandibular ligament or raphe. (Hollinshead, 1982) The pterygomandibular ligament lies between the medial pterygoid process and inner surface of the mandible. It is not a pronounced fibrous band but rather represents the junction between the buccinator and the superior pharyngeal constrictor. (Ibid.) Some anatomists describe these two muscles as being continuous with each other

(Gaughran, 1957). A 1989 study of cadavers by Shimada and Gasser demonstrated

that the superior pharyngeal constrictor and buccinator were completely contiguous in

36% of their adult specimens. (Shimada, 1989) Another 28% exhibited a fascial region that partially separated the two muscles and in the final 36% of specimens, the buccinator and superior pharyngeal constrictor were completely separated by a wide fascial region. (Ibid.) Some fibers of the buccinator continue forward to intermingle with fibers of the orbicularis oris in both the upper and lower lips while the remainder pass through the orbicularis oris to insert directly into the mucosa and skin of the lips.

(Hollinshead, 1982) So there is a direct muscular connection between the lips and the uppermost part of the pharynx in over half of adults. The significance of this muscular interaction to the clarinetist has yet to be determined.

The buccinator forms the muscular portion of the cheek. It acts to press the inner surface of the cheek against the teeth, thus it is active in the formation of the embouchure. It also functions to prevent distention of the cheek by the increased intraoral air pressure caused by playing the clarinet or any other wind instrument.

(Oatis, 2009) With the widespread application of circular breathing by clarinetists, the buccinator has been tasked with a new function. In circular breathing, the cheeks are filled with air. The posterior tongue is displaced posteriorly and superiorly, and the soft palate is displaced inferiorly and anteriorly. (Peng, 2015) Both of these motions are thought to be due to the action of the palatoglossal muscle. (Ibid.) When the soft palate meets the posterior tongue, a seal is formed which isolates the anterior oral cavity from the oropharynx. The air stored in the cheeks is then forced into the instrument as a breath is being taken through the nose to replenish the lungs. The palate and pharyngeal muscles then return to their normal duty of sealing the oral cavity from the nose, and air from the lungs once again becomes the power source for the vibrating reed. The buccinators must first relax to allow the cheeks to fill with air.

They must then contract to force the air stored in the cheeks out of the oral cavity and into the mouthpiece.

The Muscles of Mastication

Four primary muscles are involved with the movement of the mandible: the masseter, the medial and lateral pterygoids, and the temporalis. They are known collectively as the muscles of mastication. All are innervated by branches of the second division of the trigeminal nerve (CN V). A layer of superficial fascia divides at the lower border of the mandible and extends superiorly to enclose the masseter, both ptergyoids, and part of the temporalis in what is known as the masticator space. (Hollinshead, 1982)

The masseter is the large muscle that covers the ramus of the mandible. It is easily palpable when one clenches the jaw. The origin of the masseter is the inferior and inner surfaces of the zygomatic arch. It inserts into the ramus of the mandible.

The temporalis is the largest of the muscles of mastication. (Oatis, 2009) Its broad fan shaped origin is in the temporal fossa on the lateral aspect of the skull. (Hollinshead,

1982) Most of its insertion is on the medial side of the ramus of the mandible, extending as far inferiorly as the occlusal surfaces of the mandibular molars. (Ibid.)

One can palpate this muscle in the hairline just anterior to the auricle.

The medial pterygoid is located on the inner aspect of the mandible. It originates from the inner surface of the lamina of the pterygoid plate. Its fibers run downward, posteriorly, and laterally to insert on the inner aspect of the ramus where it forms a sling with the masseter on the outer side of the mandible. (Ibid.) The lateral pterygoid is the only masticatory muscle whose fibers run in a nearly horizontal orientation. Its origin is via two heads. The superior head arises from the greater wing of the sphenoid while the inferior head originates from the lateral pterygoid plate. (Ibid.)

The superior head inserts into the articular capsule and disk of the TMJ while the inferior head inserts on the neck of the condyle.

The masseter, medial pterygoid, and temporalis act together to cause forceful closure of the jaw. (Ibid.) The large cross-sectional areas of these muscles confirm their specialization for the force production necessary for chewing and grinding tough foods. (Oatis, 2009) The masseter and medial pterygoid deviate the jaw to the contralateral side while the temporalis adducts the mandible to the ipsilateral side.

(Hollinshead, 1982) These muscles work in a coordinated fashion to create the grinding motion associated with chewing. The lateral pterygoid pulls the mandible anteriorly and somewhat downward helping to position the TMJ. In point of fact, it is these muscles which are the primary stabilizers of the TMJ’s. (Oatis, 2009) The ligaments of the TMJ only function at the extremes of TMJ motion. (Ibid.)

None of the four muscles of mastication just described function to open the jaw.

Gravity is the primary mechanism of jaw opening. (Oatis, 2009) The digastric muscle does assist in opening the jaw, particularly when it needs to be opened rapidly. For this reason, the digastric is sometimes discussed with the muscles of mastication even though it is not technically a member of this muscle group.

The muscles of mastication may play a more important role in the clarinet embouchure than is often acknowledged. Electromyographic (EMG) studies, however, have reported conflicting results regarding the activity of these muscles while the clarinet is being played. Campbell employed EMG to study the activity of the temporalis, masseter and digastric muscles in ten professional clarinetists while they played the clarinet. (Campbell, 1999) She observed significant activity in the masticatory muscles tested. (Ibid.) She also noted that the activity in these muscles varied during playing in response to changing performance demands. (Ibid.)

Interestingly, the digastric muscles, which assist in opening the jaw, exhibited more activity than the temporalis and the masseter while the clarinet was being played.

(Ibid.) In their 2007 study, Gotouda, Yamaguchi, and Okada, et. al., made EMG recordings of 33 wind musicians, including seven clarinetists, while playing both mid- range and high notes. (Gotouda, 2007). They observed only very small loads on the jaw muscles tested (temporalis m. and masseter m.) in comparison with the loads measured during maximal contraction of these muscles. (Ibid.) In addition, these muscles did not exhibit significant levels of fatigue even after a 90 minute session of sustained playing. (Ibid.) Gotouda’s study did not include the digastric muscle.

Further study is warranted to clarify these discrepancies.

Figure 48. The muscles of mastication. In this lateral view the medial and lateral pterygoids are essentially concealed from view by the overlying masseter, temporalis, and mandible. ( 3D4Medical Essential Anatomy 5, © 2018. Used with permission.)

The Tongue

The tongue is a muscular organ. Anteriorly, the dorsum of the tongue is richly innervated with both sensory fibers and the more specialized taste buds. Its functions in eating and articulation, both in speaking and playing the clarinet, are critical. (McCoy,

2012) Muscles of the tongue fall into two distinct groups, the intrinsic muscles which shape the tongue, and the extrinsic muscles which move the tongue. (Oatis, 2009)

The intrinsic muscles are organized into complex bundles that run longitudinally, vertically, and transversely within the substance of the tongue. The fibers of these muscles are intertwined with each other and connective tissue septae. (Hollinshead,

1982) In the midline, the septum linguae effectively divides the tongue into two distinct sides. Only near the tip do transverse fibers cross the midline. (Ibid.) Both superior and

inferior longitudinal muscles have been described. (Ibid.) These muscles run the length of the dorsum. The superior group lies just deep to the mucosa of the tongue while the inferior group lies near the bottom of the tongue. (Ibid.) The entire dorsum of the tongue is shortened when these two muscle groups contract together. (McCoy, 2012)

Contraction of the superior group alone causes upward movement of the tip of the tongue while activation of the inferior group alone moves the tip of the tongue downward. The bulk of the tongue is formed by the horizontal and transverse fibers. In spite of their names, the fibers of both of these groups run obliquely. (Hollinshead, 1982)

The four extrinsic muscles are arranged inferiorly, posteriorly, laterally and superiorly to the bulk of the tongue. They function to support and move the tongue, (Dimon,

2008) positioning it to propel food boluses into the esophagus and to articulate various vowel and consonant sounds. (Oatis, 2009) The styloglossus originates from the styloid process at the base of the temporal bone and inserts into the posterolateral aspect of the tongue where its fibers continue anteriorly as part of the superior longitudinal muscle. (Hollinshead, 1982) The styloglossus lifts and retracts the tongue, and functions in curling the midportion of the tongue. (McCoy, 2012) This muscle also serves as a link between the tongue and base of the skull. (Dimon, 2008)

The hyoglossus arises from the greater cornu of hyoid bone and runs upward and forward to interlace with the fibers of the stylohyoid. (Hollinshead, 1982) It acts to depress the tongue and may have some involvement in tongue retraction. (Oatis,

2009) The large fan-shaped genioglossus arises from the inner surface of the anterior aspect of the mandible and attaches to the entire undersurface of the tongue. (Ibid.)

Some of its fibers extend posteriorly to attach to the middle pharyngeal constrictor while its inferior fibers extend downward to attach to the hyoid bone. (Ibid.) The genioglossus protrudes the tongue, depresses the mid-portion of the tongue, and

deviates the tongue to the opposite side. (Ibid.) The palatoglossus elevates the back of the tongue. It enters the tongue inferiorly. (McCoy, 2012) From its origin in the tendons of the tensor veli palatine in the soft palate, (Oatis, 2009) it runs beneath the mucosa of the lateral pharyngeal wall where it forms the anterior tonsillar pillar. The palatoglossus is sometimes considered a muscle of the soft palate because it functions to lower the soft palate, (Hollinshead, 1982) but it also elevates the back of the tongue. (Oatis, 2009) Perhaps its function is best described as drawing the soft palate and tongue base together during swallowing. (Dimon, 2008)

Figure 49. Three of the extrinsic muscles of the tongue. The genioglossus is a large muscle. It is labelled twice to illustrate its extent. The palatoglossus is not Figure 49, continued: shown. (Adapted from 3D4Medical Essential Anatomy 5 © 2018. Used with permission)

McCoy (2012) writes:

For optimal efficiency in phonation—both in speaking and singing— all the tongue muscles must be allowed to function with as little tension as possible. The accuracy of a vowel or consonant relies on where the tongue is placed, not how firmly it is held in position. The

attachments of the tongue to other moveable structures, including the jaw, hyoid bone and soft palate, allow a high degree of interactivity, some of which is good, some of which is not. (McCoy, 2012)

While the foregoing statement is directed toward vocalists, it could just as easily have been written for clarinetists. Tension in the tongue and its supporting muscles causes articulation to become heavy and is an impediment to rapid tonguing. Furthermore, tension is rarely limited to a single group of muscles. Keith Stein recognized this as is apparent from his writing and made it an important part of his teaching. (Stein, n.d.)

With the high degree of interconnectivity among the structures of the head, neck, oral cavity, pharynx, and spine it is easy to envision how increased muscle tension starting in one structure can spill over into interconnected areas leading to tension throughout the body.

Muscles of the Palate and Pharynx

The soft palate is a soft tissue structure which extends posteriorly and inferiorly from the bony hard palate. During swallowing, the soft palate elevates to close off the nasopharynx. In circular breathing, it descends to isolate the oral cavity from the upper airway during the nasal inhalation phase. The levator veli palatini muscles act to elevate the soft palate and pull it posteriorly. These muscles originate from the temporal bone, the carotid sheath, and the auditory tube and insert into the contralateral tensor veli palatini by way of the palatal aponeurosis. (Oatis, 2009) The tensor veli palatini originates on the sphenoid bone and the auditory tube and inserts into the palatal aponeurosis. It acts to tense the palate and works with the levator veli palatini to close off the nasopharynx. The musculus uvula has as its origins on the hard palate and from the palatal aponeurosis. It is located in the uvula (the little hangie down thingie in the back of the throat) and acts to retract the uvula. This

movement assists in the closure of the palate, but the uvula’s primary function is to assist in mucus management, collecting the excess mucus from the nose and directing it into the esophagus. The palatopharyngeus is a muscle originating from the palatal aponeurosis and the mucosa of the soft palate. It passes downward through the lateral walls of the pharynx to insert onto the posterior surface of the thyroid cartilage. This muscle elevates the pharynx thus shortening it and assisting in swallowing. It also tenses and narrows the pharynx and elevates the larynx. (McCoy, 2012)

The pharynx has three primary muscles, the superior, middle and inferior constrictors.

These muscles lie in the lateral and posterior walls of the pharynx. Their contraction constricts the pharynx, an action which assists in clearing the pharynx of any solids or liquids. (Oatis, 2009) These muscles have broad origins. The superior pharyngeal constrictor originates from the sphenoid bone, the mandible, the lateral aspects of the tongue and indirectly to the base of the occiput.(Ibid.) Its fibers run posteromedially to join fibers of the contralateral superior constrictor. Intervening between the superior and middle constrictors is the stylopharyngeus muscle. As its name implies, this muscle begins at the styloid process. It then runs forward to insert on the thyroid cartilage and the mucosal lining of the pharynx. (Ibid.) The middle pharyngeal constrictor arises from the hyoid bone and the stylohyoid ligament. It too joins with the contralateral middle constrictor, but via the median pharyngeal raphe, a coalescence of connective tissue in the posterior aspect of the hypopharynx. The inferior pharyngeal constrictor also functions to narrow the pharynx. It has its origins on the thyroid cartilage and the cricoid, and it too joins the contralateral inferior constrictor by way of the median pharyngeal raphe. (Oatis, 2009) These muscles must certainly play role in voicing on the clarinet, but this is a subject yet to be investigated.

Suprahyoid and Infrahyoid Muscles

The hyoid bone is a horseshoe shaped bone located in the anterior neck just below the mandible and above the thyroid cartilage. It does not articulate with any other bone, but from an anatomical standpoint, it is a busy place. It is here that the interconnectivity of the structures of the skull, tongue, pharynx, larynx, and even the shoulder and breastbone becomes even more apparent. As these muscles are described, the clarinetist should envision the impact that the balance of the head upon the spine has upon all of these muscles and how this interconnectivity can impact playing the clarinet.

Figure 50. The superior, middle, and inferior pharyngeal constrictors. Note how the fibers wrap posteriorly. The stylopharyngeus muscle, tiny by comparison, can be seen arising from the styloid process. (From 3D4Medical Essential Anatomy 5 ©2018. Used with permission.)

The muscles attaching to the hyoid bone are generally divided into suprahyoid and infrahyoid groups. The suprahyoid muscles include the digastric, the stylohyoid, the mylohyoid, and the geniohyoid. The origins, insertions, and actions of these muscles

are outlined in Appendix B. The suprahyoid muscles work to elevate the hyoid bone only when the mandible is fixed by contraction of the mandibular elevators (masseter, temporalis, and medial pterygoid). Since the thyroid cartilage is below the hyoid, but is connected to it by way of the infrahyoid muscles and the thyrohyoid membrane, contraction of these muscles also elevates the larynx when the mandible is fixed.

(Oatis, 2009) When the mandibular elevators are disengaged, contraction of these muscles causes depression of the mandible. Note that the stylohyoid attaches to the styloid process, thus forming an indirect link between the skull and the larynx.

(Dimon, 2008) The digastric muscle, with its origin on the mastoid process, forms another link between the larynx and the skull. (Ibid.) These relationships suggest that these muscles work most effectively when the skull is balanced atop the spine.

The infrahyoid muscles are the thyrohyoid, sternohyoid, sternothyroid, and omohyoid.

The thyrohyoid elevates the larynx, but the other infrahyoid muscles are laryngeal depressors. Note that the insertions of the sternothyroid, sternohyoid, and omohyoid are not in the neck. Both the sternohyoid and sternothyroid insert into the posterior aspect of the sternum while the inferior belly of the omohyoid attaches to the superior border of the scapula. This illustrates that tension in the shoulders may lead to tension in the anterior neck as well. Since the tongue is also connected to the hyoid by way of the mylohyoid, tension in the shoulders may also result in tension in the tongue.

Tension in the tongue and upper airway is not conducive to effortless clarinet playing.

Muscles of the Neck

The muscles of the neck may be thought of as two groups, the anterior flexor muscles, and the posterior extensor muscles. The head is balanced atop the spine where ligaments provide additional stability. But the center of gravity of the skull lies anterior to the occipital condyles creating a tendency for the head to flex forward.

This tendency is countered by the posterior extensor muscles. As a result the posterior neck muscles exhibit greater mass than do the anterior flexors. (Oatis, 2009) Kapandji

(1974) describes the muscles of the posterior neck as falling into four planes, or levels. (Kapandji, 1974) This is a useful way to approach this complex area.

Figure 52. This diagram illustrates the vectors of pull of the muscles attached to the hyoid bone. The interaction of these muscles is apparent. Adapted from 3D4Medical Essential Anatomy 5. Used with permission.)

Kapandji’s deepest layer is that of the suboccipital muscles and includes the rectus capitis posterior major, rectus capitis posterior minor, superior oblique, and inferior oblique. The actions of these muscles depend upon whether their contractions are unilateral or bilateral. These functions are outlined in Appendix B. The next layer consists of the multifidae, which consist of muscle fibers that originate from spinous processes and extend two to four vertebrae to insert on the transverse processes above.

The rotatores muscles also lie in this plane, but they are not well developed in the neck. The multifidae are quite small in the neck and probably function as little more than proprioceptors. Continuing to move outward, the next plane contains the semispinalis capitis and the semispinalis cervicis, two muscles that function primarily to extend the head. Studies have shown that when the head is balanced atop the spine, these muscles are not active. Continuing to move superiorly, the next plane includes

the splenius capitis and cervicis and the levator scapulae. The splenius muscles cover most of the posterior neck. (Oatis, 2009). The longissimus capitis is also part of this group. These muscles are especially active in head and neck extension. When the head is balanced in standing posture, these muscles are basically inactive. The levator scapulae attaches to the posterior tubercles of C1-C4 and attaches distally to the superomedial border of the scapula. This muscle is yet another example of the interconnectivity of the neck with the shoulder. Earlier, the connection of the hyoid bone with the scapula via the omohyoid was described. Tension in the shoulders may lead directly to tension in the neck by way of the levator scapulae. One of the functions of the levator scapulae is to act as a ‘guy wire’ to help stabilize the neck with the aid of antagonistic anterior neck muscles. Obviously, tension in the levator scapulae will cause increased tension in the antagonistic scalene muscles to preserve the stability of the cervical spine. The most superficial of the posterior neck extensors, the trapezius lies just beneath the superficial fascia in the posterior neck region. It is a large muscle, originating from the occiput, the nuchal ligament, and the spinous processes of C7-T12. It has three parts, upper, middle, and lower. It inserts on the lateral part of the clavicle, the acromion, and the spine of the scapula.

The flexors of the head and neck include the sternocleidomastoid (SCM), the scalenes

(anterior, middle, and posterior), longus colli, longus capitis, and the anterior rectus muscles. The SCM originates from two heads, one on the anterior surface of the sternum and the other on the superior surface of the medial third of the clavicle. It inserts on the mastoid process of the temporal bone. It is involved in a variety of movements of the head and neck including neck flexion, extension and rotation, but it also acts as a suspensory muscle for the thorax. (Dimon, 2008) In this way, the rib

cage is actually attached to the skull. The SCM is also an accessory muscle of respiration, becoming active during forced inspiration. (Ibid.)

The scalenes are located deep and posterior to the SCM. There are three scalenes, anterior, middle and posterior. Their primary functions relate to flexion and rotation of the neck, stabilizing the neck, and elevating the ribs as accessory muscles of respiration. (Oatis, 2009) These muscles work in opposition to the levator scapulae to produce the stabilizing guy wire effect on the cervical spine depicted in Figure 53.

The subclavian artery and the brachial plexus traverse a narrow triangular space formed by the anterior and middle scalenes and their attachments to the first rib.

(Ibid.) Constriction of this space, as may occur with muscle spasm, exercise, trauma, tension, or postural problems, may result in scalenus anticus syndrome with symptoms including paresthesias, weakness, loss of sensation and pain. (Ibid.) The origins, insertions and actions of all of the anterior neck flexors are summarized in

Appendix B.

Figure 53. The “guy wire” effect produced by the levator scapulae, a posterior neck extensor, and the scalenes (posterior, middle, and anterior), which are anterior neck flexors. The muscles create opposing forces which act to stabilize the cervical spine. (From 3D4Medical Essential Anatomy 5 © 2018. Used with permission.)

Muscles of the Shoulder

Playing the clarinet is not a taxing activity for the shoulder; nevertheless, it is an area in which many clarinetists are prone to manifest tension. As has been described, the scapula and hyoid bone are connected by way of the omohyoid muscle. The levator scapulae connects the transverse processes of C1-C6 with the scapula. Many of the shoulder muscles impact the axial skeleton. Moreover, the nerves that supply the hand must traverse the shoulder en route to the muscles and skin that they innervate. So, what happens in the shoulder doesn’t stay in the shoulder. The shoulder of the clarinetist is not subject to the loads encountered by a pitcher or quarterback, but if tension builds here, it can lead to a variety of unpleasant sequelae.

There are three groups of shoulder muscles, based upon their attachments and actions: the axioscapular and axioclavicular, the scapulohumeral, and the axiohumeral. (Oatis,

2009) The actions of the individual muscles are summarized in Appendix B. The discussion here will focus upon the functions of the groups as a whole.

The axioscapular and axioclavicular group includes the trapezius, serratus anterior, levator scapulae, rhomboid major and minor, pectoralis minor, subclavius, and sternocleidomastoid. The scapula is supported by muscles and floats on the posterior thorax (scapulothoracic joint). Its only bony connection to the axial skeleton is via the acromioclavicular joint. The main function of the axioscapular and axioclavicular muscles is to move the scapulothoracic and acromioclavicular joints. (Oatis, 2009)

These muscles also contract in groups to stabilize the scapula on the thorax. Thus this group of muscles acts to stabilize and position the shoulder girdle. (Ibid.)

Muscles of the scapulohumeral group are critical to the mobility of the shoulder. As a group, they not only move the glenohumeral joint but also function to stabilize it.

(Ibid.) Muscles of this group are the deltoid, the teres major, coracobrachialis, and the rotator cuff (supraspinatus, infraspinatus, subscapularis, and teres minor). The dynamic stability provided to the glenohumeral joint by the muscles of the rotator cuff is critical to the integrity of the joint. As has been described, the ligamentous structures of the shoulder are rather limited in their ability to provide stability to this highly mobile joint. Contraction of the muscles of the rotator cuff provides stabilization of the shoulder in all joint positions. (Ibid.)

The two axiohumeral muscles, the pectoralis major and latissimus dorsi, attach the humerus to the thorax. These are two massive muscles whose function is to add additional strength to the movements of the shoulder. In terms of shoulder range of

movement (ROM), these two muscles play a redundant role to the aforementioned shoulder muscles, but they are active in all movements of the shoulder except lateral rotation. (Ibid.)

Muscles of the Elbow

In elevating the clarinet to playing position, the elbow must be flexed. It remains flexed while the instrument is being played and is extended when the clarinet is placed on a stand or peg. These actions involve muscles that are located in the arm and most of which cross the elbow joint. The elbow is an inherently stable joint due to the ligaments that surround it, so that the muscles acting upon the elbow are primarily involved in movement. This is quite unlike the arrangement in the shoulder where most muscles have a collateral duty of stabilizing the joint. The muscles acting upon the elbow may be classified as flexors, which are located on the ventral aspect of the arm, and extensors which are located on the dorsal side of the arm. To cause the elbow to remain fixed, as in the flexion necessary for playing the clarinet, the action of both the flexors and the extensors is necessary. In this case the flexors produce the movement (flexion) and are considered the agonists while the extensors pull in the opposite direction (extension) to maintain the elbow in the desired position. The extensors are antagonists acting as the brakes for the agonist flexors. (Dimon, 2008)

This balancing act of agonist muscles balancing against antagonist muscles occurs throughout the body. Most males exhibit greater strength in both the elbow flexors and extensors than do females. Strength in these muscles declines with age in both sexe.

Additional muscles called supinators and pronators are located near the elbow where they act upon the superior radioulnar joint (SRUJ) to pronate and supinate the forearm. (Oatis, 2009) The elbow joint is strictly a hinge joint and is not directly involved in pronation and supination.

Flexor muscles of the elbow include the biceps brachii, brachialis, brachioradialis, and pronator teres. (Oatis, 2009) The flexors of the elbow are generally considered to exhibit greater strength than do the extensors. (Ibid.) The biceps brachii is probably the muscle in the arm that is most familiar to most people. Its name, “biceps,” is derived from a Latin word, which means “two heads” which succinctly describes the origin of this muscle. (Dimon, 2008) The origins, insertions, and actions of the flexors of the elbow are summarized in Appendix B.

There are two primary extensors of the elbow, the triceps brachii and the anconeus.

Both of these muscles lie on the dorsal aspect of the arm, but the triceps is the much larger of the two. The triceps derives its name from the fact that it has three heads.

The three portions of this muscle converge to form a single tendon which inserts on the olecranon process (head of the ulna) at the elbow. (Dimon, 2008)

The forearm is capable of pronation and supination, These movements do not occur at the elbow but rather at the superior radioulnar joint (SRUJ), immediately inferior to the elbow joint, and the distal radioulnar joint (DRUJ) which lies just above the wrist. These motions occur as the radius rotates around the ulna. Note that the radius is primarily involved with the wrist joint. Rotation of the radius around the ulna causes rotation of the hand positioning it to grasp and manipulate the keys of a clarinet and other objects. (Dimon, 2008) The muscles responsible for pronation include the pronator teres and the pronator quadratus. The supinator is assisted by the biceps brachii to supinate the forearm and hand. These muscles are summarized in

Appendix B.

Muscles of the Wrist and Hand

The forearm is also home to many muscles involved in the movement of the wrist, hand and digits. These are known as the extrinsic muscles of the hand and are of vital importance to the clarinetist. The flexors lie on the ventral or palmar aspect of the forearm while the extensors reside on the dorsal aspect. These muscles are characterized by their long tendons which cross the wrist en route to their insertions.

Many of these muscles are positioned in the arm such that movements of the arm alter their direction of pull thus enabling them to perform different functions. (Oatis, 2009)

Muscles that act to flex the wrist include the flexor carpi radialis, flexor carpi ulnaris, and palmaris longus. (Calais-Germain, 2014) Wrist extensors include the extensor carpi radialis longus, extensor carpi radialis brevis, and extensor carpi ulnaris. (Ibid)

Their origins, insertions and actions are summarized in Appendix B.

The forearm is home to the extrinsic flexors and extensors of the digits. The long tendons of these muscles must pass through the wrist along with the nerves and blood vessels to the hands and fingers. So the wrist is a small space packed with a variety of structures, some which move and others of which do not. The tendons are covered by synovial sheaths located along their courses which reduce the sliding friction of the tendons. Since these tendons slide several centimeters during full flexion of the digits, this is an extremely important function. (Oatis, 2009) The sheaths play an important role in delivering nutrients to tendons in the hand where they are very poorly vascularized. (Ibid) A complex retinacular system exists within the digits to keep the various tendons pulling in the appropriate directions. Extrinsic flexors of the fingers are the flexor digitorum profundus and the flexor digitorum superficialis. The extensor digitorum, extensor indicis, and extensor digiti minimi all function in extending the digits. The origins, insertions of these muscles are summarized in

Appendix B.

The flexor digitorum superficialis (FDS) splits into four tendons, all of which pass through the carpal tunnel en route to fingers II-V, but not to the thumb. These tendons split into a “Y” near the bases of the proximal phalanges before inserting on the lateral aspects of the middle phalanges. The flexor digitorum profundus also divides into four tendons. These tendons also pass through the carpal tunnel, deep to those of the FDS and also continue on to digits II-V. There they pass through the “Y’s” formed by the splits in the FDS tendons and continue to insert on the distal phalanges.

(Calais-Germain, 2014) Tendons function more efficiently when they are close to the bone, so there is an extensive system of pulleys arranged around the tendons to the digits. Each finger has five of these annular ligaments, A1 through A5, numbered proximally to distally. (Oatis, 2009) A2 and A4 attach directly to bone and are the

primary pulleys. A1, A3, and A5 attach to one of the ligaments which bind the phalanges together. Three pair of cruciate ligaments are located on the ventral surfaces of the proximal and middle phalanges. (Oatis, 2009) These pulleys are critical to the proper functioning of the tendons of the FDS and FDP. (Ibid.)

Figure 56. Flexor tendons are shown inserting on the digits. A flexor tendon sheath is demonstrated on the index finger and thumb but has been removed from the other digits. The lumbricals and the muscles composing the thenar eminence, by the thumb, and hypothenar eminence, inferior to the little finger are nicely shown. (Gray’s Anatomy, © 1918. Public domain.)

Two groups of muscles attach solely to the bones of the hands, the interossei and the lumbricals. These are the intrinsic muscles of the hand. There are four interossei muscles on the dorsal aspect of the hand and three on the palmar side of the hand.

These muscles insert on the base of the proximal phalanx, the tendon of the extensor digitorum and onto the adjacent interossei muscle (Calais-Germain, 2014). The palmar interossei adduct the fingers while the dorsal interossei abduct the fingers.

There are four lumbricals which arise from the tendons of the deep flexor muscles and insert on the tendons of the extensor digitorum. (Dimon, 2008) These muscles collectively function to flex the metacarpophalangeal joints while simultaneously extending the interphalangeal joints. (Ibid.)

The little finger has three muscles of its own. Together they form the hypothenar eminence on the medial (ulnar) aspect of the palm. The opponens digiti minimi, flexor digiti minimi, and the abductor digiti minimi function to move the little finger toward the thumb, flex the little finger at the MCP, and abduct it, respectively. (Calais-

Germain, 2014)

The superior articular surface of the metacarpal of the thumb articulates with the trapezium to form a saddle joint giving the thumb the thumb the ability to oppose the other fingers. (Calais-Germain, 2014) The thumb has four intrinsic muscles and these form the thenar eminence, the muscular pad just inferior to the thumb on the palmar surface. (Dimon, 2011) The adductor pollicis functions to adduct the thumb. Flexion and rotation of the thumb is caused by the flexor pollicis brevis. The opponens pollicis functions to oppose the thumb to the fingers. As its name would indicate, the abductor pollicis brevis abducts the thumb.

In addition to the intrinsic muscles, the thumb also has four extrinsic muscles in the forearm. The flexor pollicis longus arises from the anterior aspect of the radius. Its tendon then passes through the carpal tunnel to insert on the distal phalanx of the thumb. (Calais-Germain, 2014) This muscle creates flexion at the interphalangeal joint, the metacarpophalangeal joint, and the carpometacarpal joint of the thumb. The abductor pollicis longus arises on the posterior surfaces of the radius, the interosseous ligament, and ulna. Its tendon passes through the extensor retinaculum to insert on the metacarpal of the thumb. It produces anteromedial movement of the thumb and assists in flexion of the wrist. (Ibid.) Originating inferior to the abductor pollicis longus, the extensor pollicis brevis acts to produce extension of the metacarpophalangeal and carpometacarpal joints of the thumb. The extensor pollicis longus arises inferior to the

to the extensor pollicis brevis. The extensor policis longus is the only muscle able to extend the interphalangeal joint of the thumb. (Ibid.)

The Thorax and the Muscles of Respiration

The rib cage has been described in Chapter I. The ribs articulate with the spine by way of the costovertebral joints. These joints allow a limited amount of rotation of the ribs during respiration. These joints are small, but the ribs are very long, so small movements in the costovertebral joints result in much larger movements over the length of the ribs. (Dimon, 2008) When combined with the flexibility and gliding movements of the costochondral joints at the sternum, the ribs are able to elevate and descend causing changes in the dimensions of the thorax. These dimensional changes are essential to the mechanics of breathing. (McCoy, 2012)

Numerous muscles throughout the body contribute to the movements of respiration.

The primary muscle of inspiration is the diaphragm. This muscle is perhaps the best known muscle of respiration to most clarinetists. It is also one of the most misunderstood. Located within the rib cage, the diaphragm is a large, flat, dome- shaped muscle which has three major origins: sternal, costal, and vertebral. The sternal origin is the inner aspect of the xiphoid process at the bottom of the sternum.

The costal origin is from the inner aspects of ribs seven through twelve. These fibers interdigitate with fibers of the transversus abdominis. (Calais-Germain, 2014) Finally, the vertebral origins consist of the attachments of two crura and five arcuate ligaments which attach to the lumbar spine. All of the fibers converge to insert on the central tendon of the diaphragm. There are three openings in the diaphragm near the spine through which the aorta, inferior vena cava, and esophagus pass. The diaphragm divides the thorax from the abdominal cavity. Its location is higher in the trunk than is

often appreciated by wind and brass players and singers. (McCoy, 2012) This has pedagogical significance for teachers of clarinet working with their students on breathing. When one places a hand upon the abdomen during inspiration, it is the movement of the abdominal viscera as a result of diaphragmatic contraction that is being felt. It is not possible to feel the diaphragm contract directly.

Figure 58. The diaphragm seen from below. Note the crural attachments to the anterior aspects of L1-L4 vertebrae. The central tendon appears lightly shaded in this illustration while the muscular portion of the diaphragm is red. The openings for the inferior vena cave, the aorta and esophagus are visible. (Gray’s Anatomy ©1918. Public domain.)

The diaphragm is a one way muscle. It contracts during inspiration. Contraction causes the diaphragm to descend, which increases the volume of the thorax. Because the lungs are adherent to the inside of the thorax, the volume of the lungs also increases. This results in a negative pressure (lower than the ambient atmospheric

pressure) within the thorax and lungs. Air enters the lungs in order to resolve this disequilibrium. The diaphragm acts just like a plunger in this process. (Ibid.) The thorax may be thought of as a gas-filled container, like a balloon, that is compressible and able to change its shape. (Calais-Germain, 2014) In contrast, the abdominal cavity is more like a water filled balloon. Its shape can change, but its volume remains the same. When the diaphragm descends, it pushes down on the abdominal contents. One can see the external results of this in expansion of the abdomen and/or back during inspiration. (McCoy, 2012) During expiration, the diaphragm relaxes and returns to its original position. This process occurs as a result of elastic recoil and involves no contraction of the diaphragm. During quiet respiration, the act of exhalation is entirely passive. (Ibid.) For the clarinetist who is controlling the air supply entering the mouthpiece, quiet inspiration and passive expiration are not sufficient. More muscles need to become involved.

The diaphragm is a voluntary muscle, meaning that one can inhale whenever one chooses. But for most of the approximately 20,000 breaths taken by most people on a daily basis, the diaphragm contracts reflexively whenever a breath is required. (Oatis,

2009) It is responsible for about 70% of tidal volume, the amount of air inspired and expired during quiet breathing. (Ibid.) During relaxed breathing, the diaphragm receives assistance from the parasternal intercostal muscles and the scalene muscles in the cervical region. (De Troyer, 2005) Here is yet another example of interconnectivity among parts of the body.

For a breath big enough to play an extended passage, the external intercostal muscles are recruited to assist the diaphragm in inspiration. These muscles arise from the lower border of each rib and run obliquely downward and forward to insert on the

upper border of the rib below. Like the diaphragm, these muscles are entirely voluntary. When the external intercostals contract, they elevate the ribs and pull them outward causing a widening of the thorax. Increasing the volume of the thorax results in increased negative intrathoracic pressure which causes more air to enter the lungs.

Exhaled air is the power source for the oscillating reed on the clarinet. Much more than a passive exhalation is necessary for this task. The internal intercostal muscles lie deep to the external intercostals. Their fibers run from the inferior border of each rib and run inferiorly and posteriorly to attach on the superior border of the rib below.

The fibers of the internal intercostals are oriented nearly perpendicular to those of the external intercostals. These muscles contract on expiration. (De Troyer, 2005; Wilson,

2001) During early expiration, there is continued contraction of the scalenes and the parasternal intercostals continue to contract eccentrically to moderate the elastic recoil of the rib cage. (Oatis, 2009) The perpendicular orientation of the fibers of the external intercostals with the internal intercostals allows them to stabilize and support the thorax when they contract simultaneously. (Ibid.) In addition, they coalesce posteriorly to form the internal intercostal membrane which runs the length of the thorax. (Ibid.) Thus, these muscles unify the thorax into a contiguous unit. (Calais-

Germain, 2014) While this is generally a good thing, in instances of postural deficiency and tension, the rib cage may become quite rigid and tight, especially in the back, thus increasing the work of breathing. (Dimon, 2008) The fibers of the innermost intercostals run parallel to the fibers of the internal intercostals. From the orientation of their fibers, it is presumed that they serve an expiratory function.

(McCoy, 2012) Finally, the transversus thoracis is located on the inner surface of the sternum. The directions of its fibers bear resemblance to a hand with the fingers spread widely apart as they run superolaterally to insert on the costal cartilages of the

second through sixth ribs. (Dimon, 2008) This muscle acts to lower anterior portion of these ribs, thus assisting in expiration. (Calais-Germain, 2014)

Abdominal muscles factor significantly in producing the expiratory control necessary for the clarinetist to achieve the initiation of sound (attack), dynamics, and musical inflection that s/he desires. There are five paired muscles which contribute to this expiratory control. In the anterior abdomen, the rectus abdominis, commonly known as the “abs,” originates at the pubis symphysis and runs superiorly and slightly laterally to insert into the fifth, sixth, and seventh ribs, and the inferior portion of the sternum. (Dimon, 2008) It is enclosed within a division of the tendinous abdominal aponeurosis called the rectus sheath. There are three transverse tendinous intersections where the rectus abdominis adheres to the anterior layer of the rectus sheath. (Calais-Germain, 2014) These divide the muscle into the four segments commonly recognized as “ripped abs.” (McCoy, 2012) The rectus abdominis is the primary flexor of the trunk. Contraction of the rectus abdominis pulls the rib cage toward the pelvis and may also create posterior tilt of the pelvis. (Calais-Germain,

2014)

Figure 59. The diaphragm in anterior view. The tendinous parts are yellow. The central tendon is not well visualized in this view. Note the level of the diaphragm in relationship to the trunk. (3D4Medical Essential Anatomy 5 ©2018. Used with permission.)

The downward pull on the rib cage does have an effect upon expiration, but the rectus muscle is not of primary importance in creating the breath control necessary for playing the clarinet. The rectus abdominis has an impact on maintenance of posture due to its function as a flexor of the trunk. In this role it assists in counterbalancing the extensor muscles of the back. (Dimon, 2008)

The external abdominal oblique originates from the fifth through twelfth ribs. Its fibers are contiguous with those of the external intercosal muscles (Ibid.) and serratus anterior. (Calais-Germain, 2014) Fibers of the external oblique run inferiorly and medially to terminate in the abdominal aponeurosis and on the iliac crest. (McCoy,

2012) Unilateral contraction results in lateral flexion of the trunk. The external obliques participate in lateral rotation of the trunk. (Calais-Germain, 2014) Bilateral contraction flexes the trunk. This is a large muscle and is an important in expiration in both wind players and singers. (McCoy, 2012)

Figure 60. The rectus abdominis is demonstrated along with its three transverse tendinous insertions. This is the muscle responsible for “ripped abs” or “six-pack” so sought after in the gym. (3D4Medical Essential Anatomy 5 ©2018. Used with permission.)

Figure 61. The external abdominal oblique muscle. (3D4Medical Essential Anatomy 5. Used with permission.)

The internal oblique originates from the iliac crest and lumbdorsal fascia posteriorly and the inguinal ligament (the groin ligament) anteriorly. (Ibid.) The fibers generally run superiorly and medially although the direction of its fibers varies depending upon their position within the muscle. (Calais-Germain, 2014) It inserts on the lowest four ribs where its fibers are continuous with the internal intercostal muscles of the thorax.

(Dimon, 2008)

Deepest of the four paired muscles of the abdominal wall is the transversus abdominis. Originating on the iliac crest and inguinal ligament below, and the five lumbar vertebrae posteriorly, its fibers run essentially horizontally to insert on the linea alba of the abdominal aponeurosis and the inner surfaces of the lowest seven ribs. (Calais-Germain, 2014) Within the thorax, its fibers interdigitate with those of the diaphragm. (Ibid.)

Figure 62. The internal abdominal oblique muscle. Note that its fibers run perpendicularly to those of the external abdominal oblique. (3D4Medical Essential Anatomy 5. Used with permission)

The transversus abdominis encircles the abdomen much like a girdle. Its contraction decreases the diameter of the abdomen. It may act to either pull in the tummy or increase lumbar lordosis depending upon the antagonistic contractions of other muscles in the abdomen and back. (Ibid.)

The quadratus lumborum is a muscle of the lower back originating posteriorly on the iliac crest to insert on the twelfth rib and the transverse processes of the lumbar vertebrae. Its fibers run both vertically and obliquely. (Ibid.) Unilateral contraction may result in elevation of the pelvis on one side or sidebending of the trunk, (Ibid.) but its functions in expiration and maintenance of posture are of more significance to the clarinetist. During expiration, these muscles contract to assist the aforementioned

abdominal muscles by stabilizing the lower back, thus directing the abdominal contents superiorly rather than allowing them to expand the lower back. (McCoy, 2012)

Other muscles in the body may also participate in respiration, and most of these have already been described in relationship to the part of the body in which they are located. Basically, any muscle that can assist in elevating the thorax may be thought of as an accessory muscle of inspiration. The sternocleidomastoid in the neck can act to elevate the sternum and clavicles which assists with inspiration. The pectoralis major and minor have attachments to the sternum and clavicle, so it is possible for them to exert some lift on the thorax. The subclavian muscle is located deep to the clavicle and attaches to the first rib so has a more obvious but also more limited action in lifting the rib cage. Even the platysma in the subcutaneous tissue of the anterior

neck may engage in efforts to increase inspiratory efforts although this is generally seen only in pathological conditions.

Figure 64. The quadratus lumborum is in the lower back where it stabilizes the lower back. It also helps to stabilize the thorax and to maintain the shape of abdominal contents during expiration. (3D4Medical Essential Anatomy 5 © 2018. Used with permission.)

Numerous muscles in the back also function to enhance inspiration, and are probably more important than is generally appreciated. Most of the muscles in the back also play a major role in stabilizing the spine and maintaining upright posture.

The activity of these muscles in clarinetists has been largely overlooked. It is relatively easy to find studies on the acoustics of the clarinet and how to build technical fluency, but the actual respiratory muscular activity involved in the production of a pleasing sound remains largely undefined. The actions of the respiratory muscles during sustained notes, alterations in pitch, various articulations,

changes in volume, and all the subtleties of phrasing performed while playing the clarinet have yet to be elucidated. There are many reasons for the lack of study into this area. From a practical standpoint, there are the issues of access and availability of equipment, as well as expertise to use it and interpret the results. Except in rare university settings it is unlikely that a clarinetist could assemble the resources necessary to conduct such studies. Conversely, physiologists who might be interested in pursuing such work are unlikely to interact with clarinetists and are usually already engaged with projects that consume both their time and lab resources. Funding, of course, is always an issue.

In spite of such limitations, some studies have been done. Most of the studies on musicians’ breathing seem to involve vocalists or brass instrumentalists. Most of these findings probably apply to clarinetists as well, but care must be taken not to assume that the breathing patterns of a trumpet player or a singer accurately describe what happens when the clarinet is played. The physical demands of performing are instrument specific. (Cugell, 1986) The maximal oral pressure for a trumpet player is estimated at 132 mmHg with a maximal airflow of 0.40 L/sec. while a flautist generates a maximal intraoral pressure of 78 mmHg and a maximal airflow of 0.61

L/sec. (Ibid.) The clarinetist generates a maximal oral pressure of 55 mmHg and a maximal flow rate of 0.96 L/sec, so the contraction strategies of the thoracic and abdominal muscles are unlikely to be identical for all three of these wind players.

(Ibid.)

100

Chapter 4: Posture

Merriam-Webster defines “posture” as, “the position or bearing of the body whether characteristic or assumed for a special purpose.” (Merriam-Webster Dictionary, 2018)

In 1947, the Posture Committee of the American Academy of Orthopedic Surgeons approved the following definitions which are still used today. (Chai, 2007)

Posture: the relative arrangement of the parts of the body

Good Posture: the state of muscular and skeletal balance which protects the supporting structures of the body against injury or progressive deformity irrespective of the attitude in which these structures are working or resting Poor Posture: increased strain on the supporting structures and in which there is less efficient balance of the body over its base of support

Neither of these definitions emphasizes the point that Posture is NOT a Position.

Posture results from the combined forces of muscles and gravity acting upon the body’s skeletal structures. (Fortin, 2011) An optimal posture requires a minimal expenditure of energy to sustain and places the body under minimal stress. (Brockman, 1992) If the bones are properly aligned, the muscles are required to do less work. (Swift, 1985) It is important to note that posture is dynamic. It must change as the body moves. (Ibid.)

Any attempt to “hold” good posture will result in increased muscle tension which can interfere with freedom of movement in the arms and hands, restrict breathing, and increase energy expenditure, none of which is helpful for the clarinetist. (Kind, n.d.;

Shoebridge, 2017) The Alexander Technique favors the concept of “postural balance”

101

which recognizes that since the body is continually in motion, “ideal” posture must vary from moment to moment. (Kind, n.d.) The human body is designed to move. Optimal posture is a continually moving target. Posture is NOT a position!

Posture is of great importance to the clarinetist. Performance-related musculoskeletal disorders (PRMDs) affect a vast proportion of musicians with reported prevalences of

25% to 93%. (Brockman, 1992; Blanco-Pineiro, 2015; Blanco-Piniero, 2017). Of these, around 75% report impaired proficiency in playing their instrument. (Blanco-

Pineiro, 2015) These numbers include a wide range of instrumentalists including clarinetists. The common denominator in all of these studies is that impaired posture increases the risk of PRMDs. (Blanco-Pineiro, 2015; Blanco-Piniero, 2017;

Brockman, 1992; Nyman, 2007; Shoebridge, 2017) Thus achieving and maintaining good posture should be a primary goal of every clarinetist. Attention to posture should be emphasized in every stage of teaching the instrument.

In a recent study, Baadjou, et al (2017), compared the muscle activity and sound quality in twenty clarinetists playing in two different sitting postures, their habitual posture and a position (EXP) based upon Mensendeik somatocognitive therapy.

(Baadjou V. v.-B., 2017) Mensendeik postural exercise therapy is based upon body awareness, awareness of tension and relaxation, controlled movement, balanced posture, and functional breathing. The investigators concluded that the change in posture corresponded with changes in both muscle activity and sound. In terms of muscle activity, the left upper trapezius exhibited less activity in EXP than in the habitual posture. (Ibid.) Since the upper trapezius is frequently a repository for tension, lessening of the activity of this muscle may be of benefit to the performing clarinetist. In this study the right brachioradialis, a muscle subject to protracted static

102

loading in supporting the weight of the clarinet, also demonstrated less activity in

EXP. Reducing or eliminating redundant activity in these muscles should result in less fatigue and perhaps decrease the occurrence of PRMDs. Finally, 14 of the 20 clarinetists subjectively experienced an improvement in their sound when playing in

EXP. (Ibid.) Audio recordings of playing in both postures were blindly reviewed by three experienced musicians, none of whom were clarinetists. (Ibid.) They were able to discern differences in sound quality between the recordings made in the habitual vs. the EXP, but there was no consensus regarding which constituted the better sound.

(Ibid.) This is an area into which further investigation should be made. Clarinetists would be more likely to actively pursue techniques for improving muscle balance and posture if improvement in sound were a proven benefit.

Although there are a number of 3D posture analysis systems available, some of which are capable of motion analysis, these are not readily available to most clinicians

(Fortin, 2011)—or clarinetists. Thus, posture is most commonly assessed visually. The line of gravity or vertical plumb line is frequently used as a starting point to assist with postural evaluations. When standing, this line begins at the external auditory meatus and extends downward through the acromion, or point of the shoulder, then slightly posterior to the hip joint, and anterior to the knee and ankle. (Neumann D. A., 2017)

These landmarks make it possible to obtain an estimate of an individual’s postural alignment through simple observation. (Fortin, 2011) One can obtain a fairly good estimation of one’s own static body alignment by standing with his/her back against a wall. With the heels a couple of inches from the wall and feet shoulder width apart, one stands in front of a wall. The occiput, shoulder blades, and buttocks should touch the wall. There should be enough room to comfortably slide the hand between the lower back (lumbar spine) and the wall. The information gained from this exercise can

103

be useful in providing information before and during postural retraining, but it is important to remember that posture is dynamic. A static postural evaluation is much like a freeze frame from a full length motion picture. It doesn’t tell the whole story.

Figure 65. Rigid military posture—head up, chin in, shoulders back, chest out, stomach in—is an example of bad posture. Contrast the diagram of neutral posture on the left with the photo on the right. Notice the differences of the two postures with respect to the vertical plumb lines. The natural line of gravity is displaced posteriorly. The spinal curvatures are distorted. The body weight has been transferred posteriorly and is finally transmitted through the heel of the foot, negating the supportive aspects of the arches. In addition, the individual is holding this posture. The resultant tension is clearly evident (Public Domain images.)

As the line of gravity passes down the spine, it falls just to the concave sides of each of the vertebral segments: posterior to the cervical spine, anterior to the thoracic spine, posterior to the lumbar spine and anterior to the sacrum. When posture is optimal, the force of gravity creates torque that helps to maintain the normal curvatures of the spine. (Neumann D. A., 2017) These same gravitational forces can

104

become quite high if posture is extremely abnormal and may result in muscle tension and overuse with associated pain. (Ibid.) Abnormal postures may eventually cause changes in the curvatures of the spine which can lead to a variety of pathologies resulting from the increased stresses being placed upon bones, joints, spinal nerve roots, and intervertebral discs. (Gibbons, 2017; Neumann D. A., 2017) The volume of body cavities may also be altered by changes in the spinal curvature. (Neumann D. A.,

2017) Of special interest to the clarinetist is that increased thoracic kyphosis, as may be seen in forward head posture, can result in a significant reduction in the space available to the lungs for expansion during deep breathing. (Ibid.) .

In standing posture, the weight of the body is transmitted downward to the feet. The feet and ankles must be able to continually adjust to movements of the body above and irregularities in the surfaces below them. (Rolf I. , 1989) Ida Rolf points out that imbalances in the upper body are reflected in the relationships and mechanics of the feet and ankles. (Ibid.) Conversely, abnormal postural relationships within and between the feet and ankles may initiate a series of compensatory mechanisms that alter the alignment of the entire body, from the feet all the way up to the occiput. (Gibbons, 2017)

Figure 66. The three arches of the foot create a stable platform through which the body weight is transmitted to the ground below.

105

Recall that each foot has three arches, the medial and lateral longitudinal arches and the transverse arch. Ideal standing posture arranges the body’s weight so that it can be distributed over these three arches in manner that promotes maximal stability. Due to the rich sensory innervation of the plantar surfaces of the feet, even the most subtle shift in body weight results in a signal to the brain to initiate a compensatory reaction.

(Ibid.)

Pronation is the most commonly observed asymmetrical foot position. It causes the talus to exert excessive upward force on the distal tibiofibular joint which in turn forces the proximal tibiofibular joint upward. This results in narrowing of the lateral aspect of the knee joint space and may ultimately cause degeneration of the lateral meniscus and lead to osteoarthritis. (Ibid.) These changes in lower limb alignment also result in increased stress upon the pelvis and lumbar spine. (Norris, 2015)

106

Sitting posture is important, too, inasmuch as most clarinetists do the majority of their practice, rehearsals, and performing while seated. In the sitting position, the weight of the upper body is transmitted to the chair via the ischial tuberosities in a manner somewhat reminiscent of the feet of a penguin. (Kind, n.d.) Additional support for the weight of the upper body is provided by the thighs on the chair and the feet on the floor so that here again, the tripods formed by the three arches of the foot provide additional stability. The clarinetist’s feet balance him/her in the chair and give him/her a sense of being grounded. The line of gravity still applies but anterior rotation of the pelvis is necessary to maintain a relatively normal spinal configuration in what is referred to as the “neutral zero position.” (Ohlendorf, 2017) In the “ideal” sitting posture, the hip joints should be positioned slightly higher than the knees.

(Andrews, 2005, p. 47) In assuming a sitting position from standing, the angle at the hip is reduced from 180⁰ to around 90⁰. (Helander, 2003) Around 60⁰ of this reduction occurs at the hip joints while the other 30⁰ results from anterior pelvic tilt. (Ibid.)

107

Figure 69. Poor sitting postures. On the left, there is anterior pelvic tilt and marked forward head posture. On the right there is a common slouching posture with posterior pelvic tilt. (Bonnade n.d. Clarinetist’s Compendium, pg.1)

Figure 70. Effect of pelvic tilt on lumbar curvature. An anterior pelvic tilt exaggerates lumbar lordosis resulting in increased pressure on the posterior aspects of the vertebrae and intervertebral discs (A. and C.), a condition that may lead to a herniated disc if the disc is already unhealthy. Conversely, posterior pelvic tilt results in decreased lumbar lordosis with increased pressure anteriorly on the vertebrae and intervertebral discs. It is this latter condition that may lead to a herniated disc if the disc is already unhealthy. (Neumann, D.A. Kinesiology of the musculoskeletal system,©2017)

108

An anterior pelvic tilt is necessary to maintain lumbar lordosis when seated, and it alters the posture of the base of the spine in a favorable way as long as it is not exaggerated as in Figures 67 and 68. (Neumann D. A., 2017) The curvatures of the more cranial segments of the spine are optimized, lengthening the thoracic spine, and extending the base of the cervical spine which allows the upper craniocervical spine to adopt a more neutral, balanced position. (Ibid.) The knees should form an approximate 90⁰ angle between the lower leg and the thighs. (Andrews, 2005)

Unfortunately the chairs encountered by musicians frequently challenge even the most concerted efforts to maintain a relaxed, neutral posture. This is because most chairs are designed with factors other than posture in mind. (Andrews, 2005; Helander,

2003) Storage, stackability, appearance, and cost are frequently the primary considerations when a facility or institution makes the decision to purchase chairs to be used by musicians. (Kelnar, 1995) Although standards in the U.S., Europe, and many other international sites actually mandate that office chairs incorporate certain ergonomic design features, (Helander, 2003) seating for musicians has largely failed to keep pace. Office chairs can be adjusted for height, whereas chairs found in most rehearsal and performance spaces cannot. (Andrews, 2005) If the seat is too low, it causes the hip joints to be lower than the knees. In this configuration, the angle of hip flexion is increased creating a posterior pelvic tilt and reducing lumbar lordosis.

(Norris, 2015) This places the upper body at a mechanical disadvantage making it difficult for the spine to maintain upright balance. (Andrews, 2005) Muscles in the lower back and buttocks are recruited to assist in keeping the body vertical. Increased effort and tension result. (Ibid.) A seat that is too high for the feet to rest on the floor will result in increased pressure on the posterior thighs (Ibid.) with a corresponding decrease in tissue perfusion, as well as decreased postural stability. (Markhsous,

109

2012) If the chair has a concave seat, medial rotation of the femurs occurs. Not only is this uncomfortable, it may also cause pain in the knees and/or feet. (Kelnar, 1995) A chair with a backward sloping seat raises the knees above the level of the hips thereby tilting the pelvis posteriorly and creating a backward leaning posture. (Kelnar, 1995)

In this instance the trunk and head may be moved forward to facilitate seeing the music or the conductor resulting in forward head posture. (Ibid). Raising the arms to play the clarinet in this position may actually cause this posture to deteriorate further if the clarinetist moves his/her head farther forward in an unconscious effort to reduce the load on the arms. (Kind, n.d.)

Figure 71. These two penguins exhibit two very different postures. The penguin on the left exhibits a balanced, neutral posture. One might visualize this as good sitting posture with the weight of the upper body distributed through the ischial tuberosities (the feet of the penguin). The penguin on the right exhibits a forward head posture. He could be visualized as sitting in a rearward sloping seat and compensating by leaning forward with the upper body and neck. (© British Broadcasting Corporation. Used with permission)

Even under the most optimal conditions, sitting results in stresses within the spine.

Given the amount of time that much of today’s society, including clarinetists, spend sitting, it should not be surprising that so many people are losing the battle against

110

gravity. (Gibbons, 2017) When compared with standing, the pressure in the intervertebral discs increases by 40-50% when an individual is seated. (Helander,

2003). But, because the discs themselves are not innervated, the seated clarinetist is totally unaware of this increased load on his/her discs. (Ibid.) Prolonged sitting has been linked with L4-L5 disc pathology, (Markhsous, 2012) and a tendency for the body’s center of gravity to move forward. (Gibbons, 2017) Even in those individuals who exercise regularly, prolonged sitting is associated with an increased risk of diabetes, heart disease, and other maladies as well. (Pavilack, 2016) It is the opinion of this author that the chair is the cigarette of the twenty first century in terms of its impact on health.

The design of the chair influences the sitting posture of the user and may either contribute to, or provide relief from back pain.(Ibid.) Chair design also plays a major

111

role in pressure distribution at the body-seat interface—even greater than that of posture.(Ibid.) Pressure distribution in the buttocks and thighs during sitting influences perfusion in the tissues overlying the ischial tuberosities.(Ibid.) Hypoxia in these tissues causes much of the discomfort that is experienced during protracted periods of sitting.(Ibid) A chair should have a “waterfall” front so that it does not inhibit circulation to the lower limbs. (Helander, 2003) This design includes a slightly forward sloping seat with a rounded front, and is a feature of most office chairs. (HOF

Furniture, 2017) While some manufacturers offer “musician chairs” that are available in a variety of seat heights (Wenger Corporation, 2018) or which offer certain ergonomic features (New Jersey Institute of Technology, n.d.; Quarrier, 2005), the ergonomic flexibility of office seating has yet to arrive in the practice room.

In their 2005 study evaluating the sitting posture of subjects with postural backache,

Womersley and May concluded that there was a link between slouched sitting posture and transient backache in a study group younger than 30 years of age. (Wormsley,

2005) They also indicated that poor posture which is maintained long term may lead to far more severe back symptoms later in life including not only significant pain but also the possibility of loss of movement and function. (Ibid.) Even though most clarinetists are at least vaguely aware of the hazards of poor posture and the benefits of good posture, many do not attempt to change, and much of this resistance to change may be related to habit. If poor posture is maintained long enough, it becomes habitual and feels so “normal” that, when initially introduced, posture that supports and is kind to the body feels strange and even uncomfortable. (Andrews, 2005)

112

Figure 73. This chart represents an effort toward matching musician size with chair seat height by considering age and grade level. Unfortunately, the most important factor in determining appropriate seat height is the height of the musician which was not addressed in these recommendations.

There are a number of techniques or methods which address movement and body posture. These include the Alexander Technique, the Feldenkrais Method, Pilates,

Yoga, and Rolfing. Each of these is a complex entity, but all share the goal of increasing awareness of one’s movements in order to gain fluidity of movement, balance, and ease. (Jain, 2004) Each offers a different approach to achieving balance and freedom of movement, but all emphasize the mind-body connection. (Schlinger,

2006; Andrade, 2015; Wells, 2012; Jain, 2004) It is an interesting observation that none of these somatic education techniques was developed by a physician.

113

The Alexander Technique

Fredrick Matthias Alexander (1869-1955) was an Australian actor. Early in his career, he developed a problem with his voice that surfaced only when he performed. After consulting a number of physicians who were unable to resolve his problem,

Alexander took it upon himself to explore his own situation. (Jain, 2004) By careful observation and experimentation with positioning his head and neck, he discovered that certain habitual movements were interfering with his voice. (Ibid.) He believed that if one could stop him/herself from making a movement before actually moving, it would be possible to consciously redirect the motion to occur in a more natural manner. (Ibid.) Over time, this sequence would result in “inhibition” of the old habitual pattern and allow a more balanced, poised movement to become the norm.

For Alexander, the dynamic relationship of the head, neck, and spine were considered key components of every kind of movement. He referred to this as “primary control.”

(Schlinger, 2006) Alexander teachers use their hands to guide students in becoming more aware of their movements kinesthetically. Muscles become more available for use while tension is reduced. When confronted with a clarinet student whose breathing is exceptionally tense, Ormand suggests that the best solution is to seek an excellent Alexander teacher for the student. (Ormand, 2017) Alexander technique is taught in a number of music schools across the country. The goal is controlled, functional, and elegant movement: poise.

114

Figure 74. These three women exhibit poise and balance.

Feldenkrais Method

Moshe Feldenkrais (1904-1984) was an extremely athletic mechanical and electrical engineer. (Schlinger, 2006) He attained a black belt in judo and was an avid soccer player. While engaging in these activities, Feldenkrais sustained crippling knee injuries. (Jain, 2004) The medical options that were offered were unsatisfactory to him; so, much like Alexander, Feldenkrais sought answers to his condition by way of personal observation and experimentation. He believed that injuries were often precipitated by habitual movements. (Ibid.) In order to become more aware of his own body and its dynamics, he began experimenting by making subtle alterations in his movements. One of the principles of the Feldenkrais method is the examination of complex actions, such as playing the clarinet, to identify the component movements and eliminate extraneous motions that are not necessary for the accomplishment of the task. (Schlinger, 2006) Awareness Through Movement is usually taught in a class setting with most direction given verbally while Functional Integration is generally taught in private lessons with more of a hands-on approach. Study of the Feldenkrais

115

method leads to better balance, postural integration, increased flexibility, and spontaneity of movement. (Ibid.)

Pilates

Originally called “Contrology,” Pilates exercise emphasizes control of body position and movement. During World War I German born Joseph Pilates (1883-1967) was interred in a British camp along with other German citizens, and it was here that he developed his Contrology philosophies and programs. (Joseph Pilates, 2018) Pilates exercise, as it is now called, has certain traditional principles including centering, concentration, control, precision, flow, and breathing. (Wells, 2012) Originally used primarily by dancers, the exercises have become increasingly popular and are frequently recommended to patients with back pain due to their emphasis on stabilizing muscles of the lower back and trunk. (Ibid.) Pilates is considered a mind- body activity, and the traditional principles still apply. Because “Pilates” is no longer a registered trademark, numerous variations of the original program are now being marketed. (Ibid.) Some varieties of Pilates now seem to emphasize core strength, stability, and flexibility while including attention to muscle control, breathing, and posture. (Ibid.)

Yoga

Some 1700 years ago, Patanjali, a Hindu philosopher, wrote a book called the Yoga-

Sutra. Yoga is one of six classical Hindu philosophies that he is believed to have created. The traditional practice of yoga includes postures, or poses, meditation, and breath control, and implies a process that ultimately leads to transcendence.

(Schlinger, 2006) Certain movements are taught to create openness, alignment, and comfort. (Cole, 2010) There are a variety of yoga practices or schools, but Hatha

116

Yoga is most often taught in the United States. In addition to flexibility and strength,

Hatha Yoga emphasizes an increased consciousness of both movement and breathing.

(Schlinger, 2006) Stress reduction is also a potential benefit. (Cole, 2010)

Unfortunately, yoga classes may lead to injuries if students are not properly positioned by instructors or are placed into poses for which they are not adequately prepared. (Ibid.) There may also be a tendency for competition among students to attain certain positions or poses, and this too may result in injury. (Ibid.) Finally, there is no required course of study or certification for yoga instructors. Caveat emptor.

Rolfing

Rolfing differs greatly from the aforementioned techniques, both technically and philosophically. Developed by Ida Rolf, the basic concept of Rolfing is that of freeing up the fascial layers of the body with the goal of re-establishing natural alignment and structural integration of the body. Ida Rolf believed that fascia forms an intricate system within the body that is central to the body’s well-being and performance, both physically and psychologically, and that structural organization of the body decreases disorder at an unconscious level. (Rolf I. , 1989) It is a hands on technique which differs from other body work in that fascial layers of the body are targeted, working from superficial to deep usually in a series of ten weekly sessions. (Ibid.) During a session, the Rolfer involves the client in the process by directing him/her through movements and positions to enhance the myofascial release.

Body Mapping

Body mapping is a concept developed by William Conable. Observations of his cello students revealed that they exhibited movements based upon how they thought their bodies were organized rather than how their bodies were actually structured.

117

(Conable, 2000) The body map is the concept that an individual holds of his/her own body. (Ibid.) If this self-representation is accurate, movements become efficient, and expressive playing results. (Ibid.) In body mapping, anatomical structures, their functions, and locations are put into their correct perspectives with respect to the entire body. (Copeland, 2007) In his 2007 dissertation, Copeland outlines specific techniques that can be utilized by clarinet teachers to assist their students in developing and improving their body maps. (Ibid.)

Thus far, the discussion of posture has focused on the general posture of the body as a whole, but various parts of the body have their own postures as well. The posture of the head and neck deserve special mention.

Posture of the Head and Neck

As has been discussed, the occipital condyles rest in the facets of the atlas (C-1). The head balances atop the spine somewhat like a golf ball resting on a tee. (Pavilack,

2016) Minimal muscular effort is required to maintain the head in this position. But, since the center of gravity of the head is located in front of the occipital condyles, the head exhibits a natural tendency to fall forward. The extensor muscles in the back of the neck have evolved to become more robust in order to resist this tendency. (Oatis,

2009) When posture is optimal, the curvature of the cervical spine is lordotic.

Forward head posture (FHP) is the most common postural abnormality of the head and neck. (Silva, 2013) It frequently observed in clarinetists. It is defined by Peterson-

Kendall as ‘any alignment in which the external auditory meatus is positioned anterior to the plumbline (sic.) through the shoulder joint.’ (Peterson-Kendall, 2005) For each inch that the head moves forward of its neutral balanced position, the weight imposed upon the neck increases by about 10 pounds. (Gibbons, 2017) As the cervical

118

curvature flattens and becomes kyphotic, as occurs in forward head posture, the stresses on the anterior portions of the cervical vertebrae may increase by 6 to 10 times. (Oatis, 2009) Neck pain is a frequent complaint among individuals with FHP, especially in the short term. If FHP is maintained long enough, prolonged activation of the neck extensors occurs. Prolonged contraction results in decreased blood flow to the muscles which allows metabolic waste products to build up and may lead to pain.

(Gibbons, 2017) In addition, prolonged contraction of the neck extensors may result in an impairment of proprioception with subsequent deterioration of balance. (Silva,

2013) Most individuals with FHP also tend to exhibit at least some flattening of their lumbar spines.

Figure 75. Each inch that the head moves forward of its balance point atop the spine effectively results in an increased load of about 10 pounds on the spine. Over time, this may lead to a decrease in height, and increased thoracic kyphosis with the development of a dowager’s hump. ( © 2018 Erik Dalton. www.erikdalton.com. Used with permission.)

119

Forward head position is a common finding among clarinetists. (Rietveld, 2013) This may begin at the very outset of learning to play the clarinet if the head is brought forward to receive the instrument. From the very beginning the clarinet should be brought to the performer, not vice versa. (Ibid) An example of forward head position may be seen in Figure 74. In this photo, the author, in the foreground, exhibits relatively good head position. Her right ear and acromion process (point of the shoulder) are in a nearly vertical relationship. The clarinetist to her left, however, has a distinctly forward head position. A forward head posture leads to muscular tension in the neck and back which causes fatigue for the performer and may result in pain in the back and neck. Breathing is restricted. The long term consequences of maintaining such a head posture may be even more dramatic. The entire curvature of the spine may eventually suffer. The development of a Dowager’s hump on the superior thoracic spine may result from chronic forward head position as seen in Figure 75.

Forward head posture is not a condition limited to clarinetists. It may develop as a result of moving the head forward to improve visualization of the computer screen, the television, or while texting on the cell phone. Figure 73 demonstrates the increased load paced on the cervical spine as the head translates farther and farther forward.

120

Figure 76. The clarinetist in the foreground demonstrates relatively good head posture. The clarinetist to her left, however, exhibits a markedly forward head position, a situation seen frequently among clarinetists. (Image from photo collection of author)

Figure 77. An increased load is placed upon the neck as the head is moved forward. This may lead to increased cervical lordosis as seen in the radiograph on the left. This load is transmitted down the length of the spine. Chronic forward head position may lead to the eventual formation of a Dowager’s hump with associated loss of height and abnormal curvature of the spine. (© 2018, Erik Dalton www.erikdalton.com Used with permission)

Posture of the Hand

Similar to the foot, the hand has three arches which provide a balance between mobility and stability. As previously discussed, the proximal transverse arch is

121

formed largely by the carpal arch, its contents, and the flexor retinaculum. It is fixed and immobile. The distal transverse arch, formed by the metacarpal heads and their ligamentous attachments, is maintained by the intrinsic musculature of the hand. It is flexible. The third arch of the hand is the longitudinal arch. This arch is also maintained by the intrinsic muscles of the hand, and it is flexible. The maintenance of these arches provides a stable but flexible platform from which the MCP’s can move with precision and fluidity while raising and lowering the fingers onto the clarinet.

122

As a player becomes fatigued, the flexors tend to shorten causing increased tension.

(Brandfonbrenner, 2003) If a musician is aware, consciously or unconsciously, of an unstable finger position, extra muscle tension will be exerted in an attempt to make the finger feel more secure. This is invariably a counterproductive maneuver. Any tendency for an interphalangeal joint(s) to collapse while playing should be addressed with appropriate strengthening exercises.

One way to minimize tension in the hands and forearms while playing the clarinet is to establish an anatomically correct hand posture, one that maintains the three arches of the hand. Teachers have found inventive analogies in an effort to convey the concept of optimal hand position to their students. One such analogy is that that hand should be shaped, “as though holding a tennis ball.” (Stein, n.d.)

As it turns out, the concept of holding a tennis ball is a useful mental image. The hand assumes a natural relaxed position and all of the arches of the hand are preserved.

123

Unfortunately, it is just a concept. It is not possible to hold a tennis ball and play the clarinet at the same time. A tennis ball is too large to be held in an average sized hand while maintaining any sort of effective interface with the instrument. Its size interferes with the mechanics of operating the keys. Moreover, any attempt to retain a spherical object in the palm of the hand while playing the clarinet is unlikely to be successful.

Simply grasping a tennis ball or a racquetball to get a feel for the position, then exchanging the ball for a clarinet is not an effective technique. The hand position quickly defaults to the habitual posture that needs to be changed as soon as conscious attention is redirected to other issues. The need for something to remind the hands of where they should be WHILE playing led to the development of a simple hand position training tool. (Rolf S. , 2010) This device serves as a crutch of sorts so that muscle memory develops for the desired hand posture as the habitual posture is extinguished.

Except for the largest of hands, the size of a tennis ball interferes with manipulating the keys of the clarinet. A tennis ball has a diameter of 2.7 inches (6.7 cm). A racquetball has a slightly smaller diameter, 2.25 inches (5.7 cm) which allows it to fit more comfortably into the hand while still maintaining the arches of the hand in their correct positions. A Velcro strap attached to the racquetball secures it in the palm of the hand. This makes it possible to have the ball in the hand to maintain support while playing the clarinet. The smaller size of the racquetball causes little or no interference with the key mechanism while playing the clarinet. Players with smaller hands might need to use a ball still smaller than a racquetball. A handball, with its diameter of 1.875 inches (4.8 cm) might work well for a smaller adult hand, while a

124

whiffle golf ball, 1.68 inches in diameter (4.27 cm) might be good for a younger player, Not only is it smaller, it is also lighter because it’s hollow. The usefulness of this tool is not limited to novice players. Advanced and professional players can use it to detect subtle and possibly unwanted changes in their hand positions. It is also possible to use two of the devices simultaneously with one in each hand.

Figure 80. The tennis ball (left) has a diameter of 2.7 inches while the racquetball (right) has a diameter of 2.25 inches. The smaller diameter of the racquetball fits more comfortably into the palm of most hands. (Photo by author)

Figure 81. The racquetball is seen in the author's hand, secured by a Velcro strap. Note the natural drape of the hand over the ball resulting in a relaxed posture. (© 2010 Brad Finn. Used with permission.)

125

While this tool is helpful in shaping the hand for playing, it does not address the thumbs. The right thumb supports the weight of the clarinet. Because of the position of the thumb rest on the clarinet, the right thumb actually acts as a lever that increases the compressive force which is applied to the carpometacarpal joint of the thumb. The total force applied to the joint is even more complex, involving not only the weight of the clarinet, but also the forces applied to the joint by the flexors and extensors of the thumb. Using the thumb to push the instrument upward further increases the load. The average weight of a wood Bb clarinet is slightly less than two pounds. This force is increased several times by the time it reaches the carpometacarpal joint, so it is not surprising that this joint at the base of the thumb is a frequent source of pain for clarinetists. Osteoarthritis of carpometacarpal joint is common and the increased force brought to bear on this joint by holding the clarinet tends to exacerbate the

126

degenerative changes observed here. Degenerative changes and pain in the carpometacarpal joint of the thumb are more common in women.

One measure that is frequently employed to decrease the load on the thumb is the use of a neck strap to help support the weight of the clarinet. In 2000, Chesky et. al. demonstrated that the use of an elastic neck strap resulted in a reduction of axial thumb forces, composite forces, and composite force angles (Chesky, 2000.). None of the players involved in this study felt that use of the strap hindered their playing,

(Ibid.) but this perception is not universal. The strap necessarily draws the instrument closer to the body and places it in a more vertical position. This causes the mouthpiece to enter the mouth at a more acute angle. In order to compensate for this, the player is now likely to use the right thumb to push the instrument away from the body and to tip the head forward in order to re-establish a good angle for the mouthpiece. These compensatory maneuvers may then contribute further to forward head posture as well as induce tension in the neck and shoulders. In addition, the strap on the back of the neck creates a constant forward pull on the cervical spine. If a neck strap is used, the portion of the strap on the back of the neck should be as wide as possible to minimize forward pull on the cervical spine. To date, no studies have been performed to determine the impact of using a neck strap on the muscles of the neck, back, and shoulders. (Young, 2014)

While the neck strap works well for some players, it is not a panacea. So it is not surprising that a number of other devices are being designed to decrease the load bearing function of the clarinetist’s thumb. One such device is the thumb rest by Ton

Kooiman. The thumb rest redistributes the weight of the clarinet so that it is centered on the proximal phalanx of the thumb, nearer the carpometacarpal joint. (Kooiman,

127

2002--2015)By decreasing the length of the lever arm from the distal interphalangeal joint of the thumb, the load on the carpometacarpal joint is reduced. It is also claimed that this thumb rest encourages more active use of the thumb in playing the clarinet.

(Ibid.) The design, with its ability to be adjusted for a variety of hand shapes and sizes, is intriguing. The installation process is straightforward for an experienced woodwind repair technician, but given the expense of the device and its installation- coupled with the angst associated with the prospect of having holes drilled into one’s instrument- it is not something that most clarinetists are eager to explore on a trial basis.

Figure 83. The Kooiman Maestro2 thumb rest. (Ton Kooiman Products. http://www.tonkooiman.com/index.php/products)

Recent work by Young (2014) utilized surface electromyography (sEMG) to investigate the effect of moving the standard clarinet thumb rest to a higher or lower position on the instrument. (Young, 2014) Findings indicate that the optimal position for the thumb rest varies depending upon the individual and that no generalized recommendation for thumb rest position can be made. (Ibid.) Further research remains to be conducted to determine the most ergonomic method of supporting the clarinet.

128

Chapter 5: What Could Possibly Go Wrong?

Without question, the human body is a magnificently designed structure. Its complexity and interconnectivity, along with the fact that it is a living, breathing, and continually changing organism mean that things can go wrong. Throughout this document, various conditions troublesome to the clarinettist have been alluded to. In this chapter some of those will be revisited along with certain other health issues that may cause problems for the clarinettist. This chapter, and the entire document, are intended for informational purposes only. It is imperative to seek the care of a qualified healthcare professional for the evaluation and treatment of any health-related question.

Postural Issues

It should be apparent by now that poor posture is a causative or contributory factor in a multitude of issues facing the populace in general and the clarinetist in particular.

The human body is designed for movement, but clarinet playing is an essentially static activity. Over time, the flexor and extensor muscles responsible for keeping the body upright may become stretched and lax or shortened and tight. The resulting imbalance of the postural muscles perpetuates the inadequate posture, and it becomes habitual so that assuming a balanced posture feels foreign and abnormal. The upper and lower crossed syndromes, as described by Vladimir Janda, are examples of chronic muscle imbalance. In these conditions, muscles work at odds with each other as is illustrated in Figure 82 . (Phil, 2014)

129

In the upper crossed syndrome, there is overactivity of the upper trapezius and levator scapula muscles posteriorly coupled with shortening and tightening of the pectoralis muscles anteriorly. (Huizen, 2017) The result is weakening of the cervical flexors in the anterior neck and posteriorly in the lower trapezius and rhomboids. Stiffness and pain in the neck and/or back may result. (Ibid.) A similar process occurs in lower crossed syndrome. Here, the thoracolumbar extensors of the back and the rectus femoris and iliopsoas become overly tight while the deep abdominal muscles and gluteus maximus and minimus become weak. (Phil, 2014) These syndromes may be addressed by postural re-education techniques as described in Chapter III.

Figure 84. Upper and Lower Crossed Syndromes. These occur due to muscle tightness and weakness as indicated.

130

Ultimately, the intervertebral discs may pay the price for poor posture. Certainly not everyone with poor posture develops a herniated disc, but, in the absence of other pathology, nearly everyone with a herniated disc exhibits poor postural habits.

Playing Related Musculoskeletal Disorders

Musicians have defined playing related musculoskeletal disorders (PRMDs) as, “pain and other symptoms which are chronic, are beyond their control, and which interfere with their ability to play their instrument at their usual level.” (Zaza C. C., 1998) This definition has been widely accepted and a variety of maladies which may occur in the clarinetist fall under this category. The reported incidence of PRMDs among musicians in general varies from 39% to 94%, (Sousa, 2017; Kok, 2018) In her 2010

DMA document, McIlwain reports that 83% of clarinetists responding to her survey reported pain while playing their instruments. (Mc Ilwain, 2010) The study design raises the question of whether selection bias may have been involved, but the number does lie within the range observed in the general population of musicians. The 2017 study of Sousa, et al, reports an incidence of PRMDs in 47% of the woodwind players in their study, but the number of clarinetists was not mentioned. (Sousa, 2017) More study is warranted to determine the incidence of PRMDs in clarinet players.

A number of risk factors for the occurrence of PRMDs have been identified. Baadjou et al performed a systematic review of the literature and discovered that certain risk factors are consistently reported. (Baadjou V. R., 2016) Women are more likely to experience PRMDs than are men. (Ibid.) A history of a previous PRMD increases the risk of incurring a subsequent injury. (Ibid.) Joint hypermobility is frequently mentioned as a risk factor for injury, but reports are inconsistent and inconclusive.

(Ibid.) A positive association exists between performance anxiety and work-related

131

stress and the development PRMD’s. (Ibid.) Certain playing-related factors are also associated with an increased risk of PRMDs. An abrupt increase in practice time as might occur prior to auditions, recitals, or juries, is frequently mentioned as a significant risk factor. (Zaza C. F., 1997) Working with a different teacher, changing to more challenging repertoire, and playing a different instrument are also often mentioned as being positively associated with PRMDs. (Bird, 2013; Zaza C. F., 1997)

Body habitus, degree of muscle conditioning, technique, age, and method of instrumental support are also cited as contributing to the risk of developing PRMDs.

(Lederman R. , Neuromuscular and musculoskeletal problems in instrumental musicians, 2003; Brandfonbrener A. , 1998)

About 33% of instrumentalists presenting to the Cleveland Clinic Medical Center for the Performing Arts for the evaluation of pain are found to have specific diagnoses,

(Lederman R. , Neuromuscular and musculoskeletal problems in instrumental musicians, 2003) some of which will be discussed below. The remainder are considered to be suffering from a regional pain syndrome, also referred to in the literature as an overuse injury. (Ibid.) Overuse is used to describe injuries to tissues which have been subjected to stresses beyond their biological limits whether acutely or chronically. (Lederman R. C., 1986; Bird, 2013) Most of the overuse injuries in musicians are in the hand, wrist, and forearm although neck, shoulder, and back pain are also common. (Lederman R. , Neuromuscular and musculoskeletal problems in instrumental musicians, 2003) Clarinetists are more likely to present with symptoms of the right thumb, hand, wrist, or forearm due to the static load placed upon these structures by bearing the weight of the instrument. (Ibid.) Clinical diagnosis of regional pain syndromes is based upon findings of pain and tenderness located primarily in muscles and muscle-tendon junctions. (Ibid.) In general, there is no

132

weakness involved. (Ibid.) Other symptoms may include swelling, stiffness, tightness, cramping, and numbness. (Ibid.) Treatment is usually based upon a period of relative or complete rest followed by a gradual return to playing. Aspirin and non-steroidal anti-inflammatory drugs are sometimes recommended for symptomatic relief, but agreement on their usage in this setting is far from universal.

The right thumb is a frequent site of pain for the clarinetist primarily due to the static load borne by the thumb in supporting the weight of the clarinet. The carpometacarpal joint (CMC) at the base of the thumb is one of the most frequent sites of degenerative arthritis in the hand among the general population. (Nolan, 1989) Part of this is due to the multiple planes of movement of the thumb at this joint as well as the force multiplying effect of the kinetic chain of the thumb. A force of one pound at the tip of the thumb translates into eleven pounds of force at the CMC. (Ibid.) Sometimes pain also appears in the wrist, elbow, and shoulder as these structures are repositioned in an effort to reduce the discomfort in the thumb. (Ibid.) If a definitive diagnosis of osteoarthritis is made, initial treatment usually consists of splinting and anti- inflammatory drugs. (Ibid.) Surgical options are reserved for advanced stages of joint degeneration. (Ibid.) (Brandfonbrener A. A., 2004)

Carpal Tunnel Syndrome

The carpal tunnel is located on the palmar aspect of the wrist. This space is formed by the carpal bones and enclosed by the transverse carpal ligament. It is a busy place.

Nine tendons pass through the carpal tunnel along with blood vessels and the median nerve. Neither the bones nor the transverse ligament of the carpal tunnel are distensible so that any swelling of tendons traveling through the tunnel results in pressure on the other structures within the tunnel. The median nerve is the structure

133

most frequently affected by such pressure. Symptoms usually involve pain and/or paresthesia in the distribution of the median nerve, and impairment of dexterity is frequently observed as well. (Lederman R. , Neuromuscular and musculoskeletal problems in instrumental musicians, 2003) Sensory loss is infrequent. (Ibid.)

Symptoms are often experienced at night, and roughly half of affected patients experience bilateral symptoms. Repetitive wrist movements are frequently implicated as a causative factor, but disagreement remains concerning the validity of this contention. (Lederman R. , Neurological problems of performing artists, 2010) In any event, repetitive wrist movements are not a factor in clarinet playing, so carpal tunnel syndrome occurring in a clarinetist is likely rooted in some other etiology. Treatment is conservative initially and consists of splinting, especially at night, usually in conjunction with NSAIDS or oral steroids. If conservative measures fail, surgical decompression is usually recommended.

Figure 85. Carpal tunnel syndrome is due to compression of the median nerve within the carpal tunnel. Surgical release of the transverse carpal ligament relieves the compression.

Ulnar Nerve Entrapment

Another frequently observed entrapment neuropathy is known as cubital tunnel syndrome. At the elbow, the ulnar nerve travels through a tunnel of tissue called the

134

cubital tunnel which is located beneath the medial epicondyle of the ulna. Where the ulnar nerve runs under the medial epicondyle it is quite close to the skin. This area is commonly known as the "funny bone." (American Academy of Orthopedic Surgeons,

2018) As anyone who has ever banged this area knows, it really isn’t all that funny.

When the ulnar nerve becomes entrapped here, the patient usually experiences pain in the elbow, sometimes radiating down the ulnar side of the forearm into the hand.

(Lederman R. , Neuromuscular and musculoskeletal problems in instrumental musicians, 2003) Numbness or tingling in the little finger and the ulnar half of the ring finger are also common. (American Academy of Orthopedic Surgeons, 2018) It tends to occur when the elbow is flexed for prolonged periods. (Ibid.) Since this is exactly what clarinetists do, it is surprising that this problem is so infrequently observed in this population. Treatment is usually conservative consisting of NSAIDs and splinting, especially at night. (Lederman R. , Neuromuscular and musculoskeletal problems in instrumental musicians, 2003) If conservative treatment fails, surgery is recommended. (American Academy of Orthopedic Surgeons, 2018) Prolonged entrapment of the ulnar nerve may lead to muscle wasting in the hand which is irreversible, so it is important to treat cubital tunnel syndrome early before evidence of muscle wasting appears. (Ibid.)

135

Figure 86. The ulnar nerve is demonstrated in a normal cubital tunnel. It can become compressed here to produce cubital syndrome. (©2018 https://www.cedars-sinai.org/health-library/diseases-and- conditions/c/cubital-tunnel-syndrome.html)

Temporomandibular Joint Dysfunction

In Performing Arts Medicine (2010), James A. Howard, DDS (2010) describes the TMJ:

An evolutionary transgressor strategically suspended in limbo between medicine and dentistry. The temporomandibular joint (TMJ) is often misaligned by nature, misused by man, maligned by the medical profession, and misunderstood by most. (Howard, 2010)

The mandible is the foundation upon which the clarinetist’s embouchure is formed.

The TMJ, through a complex combination of hinge and gliding motions, is responsible for opening and closing the mandible. (Ibid.) A myriad of symptoms have been lumped under the diagnostic label of TMJ syndrome, sometimes simply referred to as TMJ. In addition to pain and tenderness in the joint, patients may complain of various combinations of headache, tinnitus, clicking in the joint during jaw movement, otalgia (earache), neck pain, and dizziness. (Ibid.) Certainly many other conditions may present with these symptoms. It is thought that clenching the jaw or grinding the teeth (bruxism) may contribute to the development of TMJ disorders.

136

The latter may occur only at night and is frequently addressed with the use of a bite guard. (Ibid.) Once the diagnosis of TMJ disorder has been confirmed, NSAIDs are usually recommended along with learning to avoid activities that place an increased load on the joints. (Ibid) Holding the phone between the shoulder and the jaw should be avoided as should positions in which chin is propped on the hand. (Ibid.) Sticky and hard foods should be avoided as well. (Ibid.) Gualtieri, reported that10% of clarinet and saxophone players in his series experienced subjective muscle discomfort related to their TMJs , just slightly less than in his control group. (Gaultieri, 1979)

Figure 87. The temporomandibular joint exhibits both hinge and gliding movements.

Thoracic Outlet Syndrome

“Symptomatic” Thoracic Outlet Syndrome (TOS) continues to be a controversial entity in terms of diagnosis, treatment, and whether it actually exists at all. (Lederman

R. , Neuromuscular and musculoskeletal problems in instrumental musicians, 2003)

In musicians, the “symptomatic” form is much more common. In the symptomatic

137

form,there are no consistent findings on either imaging or electrodiagnostic studies in contrast with the neurogenic form the diagnosis of which is confirmed by the presence of abnormal electrodiagnostic testing. The diagnostic criteria for symptomatic TOS are entirely clinical and have yet to be universally accepted. In general, however, the diagnosis of “symptomatic” TOS is based upon the following:

1. pain, usually on the ulnar side of the forearm, but possibly extending proximally

into the upper arm and distally into the hand;

2. sensations of tingling, numbness, or burning, usually on the ulnar side of the

forearm, but possibly extending proximally into the upper arm onto the radial

aspect of the forearm

3. symptoms are usually associated with specific positions or activities, but may

progress to a point where they are continual.

4. maneuvers such as abduction and extension of the arm, hyperextension of the

arm, and downward traction on the arm may reproduce symptoms; and

5. normal physical exam without detectable weakness, sensory, or reflex deficit

Even though a large number of musicians presenting to performing arts medicine clinics are diagnosed with this entity, it is more often seen in string and keyboard players. In a series of 73 patients with TOS, only 12 were woodwind players, 9 of whom were flautists. Clarinettists seem to be relatively immune to this disorder, even though the postural imbalances commonly observed in clarinettists are often cited as predisposing factors.

138

Figure 88. Thoracic outlet syndrome. In this figure, the clavicle has been removed to allow visualization of the nerves exiting between the anterior and middle scalenes. Surgery is indicated only for true neurogenic thoracic outlet syndrome , (© 2018. Wikipedia.com https://en.wikipedia.org/wiki/Thoracic_outlet_syndrome)

Focal Dystonia

Dystonia is a syndrome characterized by sustained muscle contractions, which may result in twitching, repetitive movements and/or abnormal postures. (Schuele, 2003)

In woodwind players, focal dystonias (FD) are rare and seemingly limited to the embouchure, the hand, or the arm. (Ibid.) In contrast to other PRMD’s, focal dystonia is more common in men than women. The onset of FD is insidious, usually evolving over a course of six months to a year. (Ibid.) In clarinetists, FD has been reported in

139

both the embouchure and the hand, usually the right. (Ibid.) The cause of this debilitating condition remains elusive, although functional MRI (fMRI) studies of the brains of musicians suffering with this disorder suggest that the underlying problem may be related to a maladaption of the neuroplasticity within the brain. (Haslinger,

2010) It is known that musicians as a group exhibit cortical sensorimotor reorganization within their motor cortices due to repeated movement sequences associated with the mastery of their instruments. (Ibid.) For most musicians, this is a good thing. In FD, however, brain plasticity goes too far and leads to abnormal sensorimotor processing. (Ibid.) Treatment options for FD are largely disappointing.

About half of the musicians diagnosed with FD are unable to return to a performing career. (Schuele, 2003)

Miscellaneous Conditions

At some point in his/her life, nearly everyone is involved in some form of trauma.

Clarinetists are no exception. Trauma may range from a minor annoyance to a life threatening event. In his upper extremity orthopedic practice, Dawson evaluated 148 musicians over a five year period. (Dawson, 1988) Nearly half of these were seen for trauma including lacerations, fractures, sprains, and strains. (Ibid.) Many of these were sports-related injuries with the majority occurring while playing baseball, softball, and basketball. (Ibid.) Other sports including volleyball, tennis, skateboarding, and cycling were also responsible for trauma producing events. (Ibid.)

Recently, there has been an increased interest in climbing as a recreational activity.

Finger injuries are the most commonly sustained injuries in the sport. (DeStephano,

2017) A2 pulley injuries are among the most common of these finger injuries. Use of correct technique in climbing reduces the risk of pulley injuries. (Ibid.)

140

Hypersensitivity pneumonitis is an exaggerated immune response triggered by exposure to an offending antigen. The symptoms initially present similarly to an acute pulmonary infection but may progress to cause serious damage to the lungs. (Okoshi,

2017) Multiple inhaled antigens may cause this disorder. It has been reported in saxophonists where it has been confirmed that their instruments were contaminated with fungal species. While hypersensitivity pneumonitis has not been reported in clarinetists, it is more commonly seen in instances where the same instrument is used by multiple players with inadequate cleaning between users. Given the metal necks of bass clarinets, alto clarinets, and basset horns in school owned instruments, the possibility of this occurring in students using these instruments are very real. This is an area which should be explored further.

141

Conclusion

Various aspects of the human structure have been presented, with emphasis on the skeletal and muscular systems. This is far from an encyclopaedic treatise, but rather is intended as an overview to assist those who play and teach the clarinet in developing an understanding of just how important his/her body’s structure and movement are in enabling him/her to engage in performance at the highest level. This is an aspect of clarinet playing that has been largely overlooked or even misstated in pedagogical literature through the years. Posture is critical to realizing the fullest potential of the body, and certain aspects of playing the clarinet may predispose one to postural habits that not only limit one’s playing but also place strain upon one’s body. Injury may be the ultimate result of such misuse. Fortunately, there are techniques available to enable mindful use of the body to overcome poor postural habits and lead to greater ease of movement. In spite of the most optimal maintenance, however, things can go awry in a machine as complex as the human body. A few such conditions have been touched upon.

In conclusion, then, the human body is both complex and highly interconnected.

Much research and study remain to be done to elucidate the complicated and intricate interactions within the body and exactly how the clarinetist can adapt them to enhance performance on his/her instrument. It is clear, though, that harmonious function of the body is essential for the clarinetist to perform at his/her highest level. In the final analysis, playing the clarinet is truly an activity involving the entire body.

142

References

American Academy of Orthopedic Surgeons. (2018). Ulnar nerve entrapment at the elbow (cubital tunnel syndrome). Retrieved from OrthoInfo: https://orthoinfo.aaos.org/en/diseases--conditions/ulnar-nerve-entrapment-at-the- elbow-cubital-tunnel-syndrome/

Andrade, L. M. (2015). Application of Pilates principles increases paraspinal muscle activation. Journal of Bodywork & Movement Therapies, 62-66.

Andrews, E. (2005). Muscle management for musicians. Lanham, MD: The Scarecrow Press.

Baadjou, V. R. (2016). Systematic review: risk factors for musculoskeletal disorders in musicians. Occupational Medicine, 614-622.

Baadjou, V. v.-B. (2017). Playing the clarinet: influence of body posture on muscle activity and sound quality. Medical Problems of Performing Artists, 125-131.

Bird, H. (2013). Overuse syndrome in musicians. Clin Rheumatol, 475-479.

Blanco-Pineiro, P. D.-P. (2015). Common postural defects among music students. Journal of Bodywork & Movement Therapies, 565-572.

Blanco-Piniero, P. D.-P. (2017). Musicians, postural quality and musculoskeletal health: A literature's review. Journal of Bodywork & Movement Therapies, 157-172.

Bonade, D. (n.d.). Clarinetist's compendium. Kenosha, WI: Leblanc Educational Publications.

Brandfonbrener, A. (1998). The etiologies of medical problems in performing artists. In R. B. Sataloff, Performing arts medicine (pp. 19-45). San Diego, CA: Singular.

Brandfonbrener, A. A. (2004). Thumb pain in an instrumental musician. Medical Problems of Performing Artists, 181-185.

Brandfonbrenner, A. (2003). Musculoskeletal problems of instrumental musicians. Hand Clinic, 231-239.

Brockman, R. T. (1992). Anatomic and kinesiologic considerations of posture for instrumental musicians. Journal of Hand Therapy, 61-64.

Calais-Germain, B. (2014). Anatomy of Movement. Seattle: Eastland Press.

Campbell, B. H. (1999). An exploratory study of the functioning of selected masticatory muscles during clarinet playing as observed through electromyography. Bloomington: Indiana University.

143

Chai, H. M. (2007, January 14). Definition of Erect Posture. Retrieved January 23, 2018, from Kinesiology Outline: http://www.pt.ntu.edu.tw/hmchai/Kinesiology/KINapplication/StancePostureDefiniti on.htm

Chesky, K.S.,Kondraske, G., and Rubin, B. (2000) Effect of elastic neck strap on right thumb force and force angle during clarinet performance. Journal of Occupational and Environmental Medicine, 775-776.

Christian, E. L. (2009). Structure and Function of the Bones and Joints of the Pelvis. In C. A. Oatis, Kinesiology: The mechanics & pathomechanics of human movement (pp. 620- 654). Baltimore: Lippincott Williams & Wilkins.

Cole, R. (2010). Easy seat: strengthen your lower back and free yourself from back pain in sitting poses. Yogajournal.com, 75-80.

Conable, B. (2000). What every musician needs to know about the body: the practical application of body mapping to making music. Portland, OR: Andover Press.

Copeland, S. (2007). Applied anatomy in the studio; body mapping and clarinet pedagogy. Greensboro: University of North Carolina at Greensboro.

Corton, M. M. (2005). Anatomy of the pelvis: how the pelvis is built for support. Clinical Obstetrics andGynecology, 48(3), 611-626.

Cugell, D. W. (1986). Interaction of chest wall and abdominal muscles in wind players. Cleveland Clinic Quarterly, 15-20. daniel. (2011, December 12). Chiropractic Q & A. Retrieved December 15, 2017, from I Live Chiropractic: http://ilivechiropractic.com/qa/221/what-are-the-17-muscles-that- attach-to-the-scapula

Dawson, W. (1988). Hand and upper extremity problems in musicians: epidemiology and diagnosis. Medical Problems of Performing Artists, 19-22.

De Troyer, A. K. (2005). Respiratory action of the intercostal muscles. Physiological Review, 717-756.

DeStephano, M. (2017, October). Finger pulley injuries explained. Retrieved from MesaRim.com: https://mesarim.com/sd/articles/climbing-article/finger-pulley- injuries-explained

Dimon, T. (2008). Anatomy of the moving body: A basic course in bones, muscles, and joints. Berkeley, CA: North Atlantic Books.

Dimon, T. (2011). The body in motion: Its evolution and design. Berkeley, CA: North Atlantic Books.

Fortin, C. F. (2011). Clinical methods for quantifying body segment posture: a literature review. Disability and Rehabilitation, 367-383.

Gaughran, G. R. (1957). Fasciae of the masticator space. The Anatomical Record, 383-400.

144

Gaultieri, P. (1979). May Johnny or Janie play the clarinet? American Journal of Orthodontics, 260-276.

Gibbons, J. (2017). Functional anatomy of the pelvis and sacroiliac joint: a practical guide. Berkely, CA: North Atlantic Books.

Gotouda, A. Y. (2007). Influence of playing wind instruments on activity of masticatory muscles. Journal of Oral Rehabilitation, 645-651.

Hansen, J.T. (2010)Netter's anatomy coloring book. Philadelphia: Saunders.

Haslinger, B. A. (2010). Sensorimotor overactivity as a pathophysiologic trait of embouchure dystonia. Neurology, 1790-1797.

Helander, M. (2003). Forget about ergonomics inn chair design? Focus on aesthetics and comfort! Ergonomics, 1306-1319.

HOF Furniture. (2017). What is waterfall seat design and how it is important for your health? Retrieved January 26, 2018, from HOF furniture and more: https://shop.hofindia.com/blog/what-is-waterfall-seat-design-and-how-it-is- important-for-your-health/

Hollinshead, W. H. (1982). Anatomy for Surgeons (third ed., Vol. v. 1 The head and neck). Philadelphia: Harper & Row, Publishers, Inc.

Hoppman, R. A. (2010). Chapter 11: Musculoskeletal problems of instrumental musicians. In R. Sataloff, A. G. Brandfonbrener, & R. J. Lederman, Performng Arts Medicine (Third edition ed., pp. 207-227). Narberth, PA: Science & Medicine.

Horvath, J. (2009) Playing (less) hurt: an injury prevention guide for musicians, Minneapolis: Janet Horvath. www.playinglesshurt.com

Howard, J. (2010). Temperomandibular joint disorders, facial pain, and dental problems in performing artists. In R. B. Sataloff, Performing Arts Medicine (pp. 151-196). Narberth, PA: Science & Medicine.

Huizen, M. (2017, August 11). Upper crossed syndrome: causes, symptoms, and exercises. Retrieved from Medical News Today: https://www.medicalnewstoday.com/articles/318897.php

Iglarsh, Z. A., & Oatis, C. A. (2004). Structure and function of the articular structures of the TMJ. In C. Oatis, Kinesiology: the mechanics and pathomechanics of human movement (pp. 438-465). Baltimore: Lippincott Williams & Watkins.

Jain, S. J. (2004). Alexander technique and Feldenkrais method: a critical overview. Physical Medicine and Rehabilitation Clinics of North America, 811-825.

Joseph Pilates. (2018, February 14). Retrieved February 26, 2018, from Wikipedia: https://en.wikipedia.org/wiki/Joseph_Pilates

Kapandji, I. A. (1974). Physiology of the joints: Trunk and vertebral column. New York: Churchill Livingstone.

145

Kelnar, A. F. (1995). Musical chairs: ergonomic consideration in chair design. British Journal of Therapy and Rehabilitation, 17-22.

Kind, E. (n.d.). An Alexander technique approach to the clarinet.

Kok, K. G. (2018). The high prevalence of playing-related musculoskeletal disorders (PRMDs) in amateur musicians playing in student orchestras: a cross-sectional study. PLoS ONE https:://doi.org/10.1371/journal.pone.0191772, 1-12.

Kooiman, T. (2002--2015). Ton Kooiman Products. Retrieved March 3, 2018, from Ton Kooiman Woodwind Ergonomics: https://www.tonkooiman.com/index.php/products

Kycia, C. (1999). Daniel Bonade: a founder of the American style of clarinet playing. Captiva, FL: Captiva Publishing.

Lederman, R. (2003). Neuromuscular and musculoskeletal problems in instrumental musicians. Muscle & Nerve, 549-561.

Lederman, R. (2010). Neurological problems of performing artists. In R. B. Sataloff, Performing Arts Medicine (pp. 51-75). Narberth, PA: Science & Medicine.

Lederman, R. C. (1986). Overuse syndromes in instrumentalists. Medical Problems of Performing Artists, 7-11.

Little, S. (2017, December 30). The arches of the foot. Retrieved January 18, 2018, from TeachMeAnatomy: http://teachmeanatomy.info/lower-limb/misc/foot-arches/

Madden, C. (2014) Integrative Alexander Technique practice for performing artists: onstage synergy. Chicago: Intellect, The University of Chicago Press.

Madden, C., Juhl, K. (2017) Galvanizing performance:the Alexander Technique as a catalyst for excellence. Philadelphia, Jessica Kingsley Publishers.

Markhsous, M. L. (2012). The effect of chair design on sitting pressure distribution snd tisue perfusion. Human Factors, 1066-1074.

Matsuki, K. O., Matsuki, K., Mu, S., Sasho, T., Nakagawa, K., Ochiai, N., et al. (2010). In vivo kinematics of normal forearms: Analysis of dynamic forearm rotation. Clinical Biomechanics, 25, 979-983.

Mc Ilwain, J. K. (2010). Common injuries among college clarinetists: definitions, causes, treatments, and prevention methods. DMA Document. Tallahassee, FL: Florida State University.

McArdle, W. D. (1996). Exercise physiology: energy, nutrition, and human performance (4th ed. ed.). Baltimore: Williams & Wilkins.

McCoy, S. (2012). Your voice: an inside view. Delaware, OH: Inside View Press.

Meals, R. A. (2008). The hand owner's manual. College Station: Virtualbookworm.com Publishing Inc.

146

Merriam-Webster Dictionary. (2018). Retrieved January 23, 2018, from Merrian Webster: https://www.merriam-webster.com/dictionary/posture

Mofatt, M., & Vickery, S. (1999). The American physical therapy association book of body maintenance and repair. New York: Holt Paperbacks.

Neuman, D. (2010). Kinesiology of mastication and ventilation. In D. Neuman, Kinesiology of the musculoskeletal system:foundations for rehabilitation (pp. 437-468). St. Louis: Elsevier.

Neumann, D. (2010). Shoulder Complex. In D. Neumann, Kinesiology of the musculoskeletal system: foundations for rehabilitation (pp. 119-173). St. Louis: Elsevier.

Neumann, D. A. (2010). Axial skeleton: osteology and arthrology. In D. A. Neumann, Kinesiology of the musculoskeletal system:Foundations for rehabilitation (pp. 319- 389). St. Louis: Elsevier.

Neumann, D. A. (2017). Kinesiology of the musculoskeletal system: foundations for rehabilitation (Third ed.). St. Louis: Elsevier.

New Jersey Institute of Technology. (n.d.). NJIT designer creates ergonomic chairs for musicians. Retrieved January 26, 2018, from NJIT: New Jersey Institute of Technology: http://www6.njit.edu/features/sceneandheard/orchestra-seats.php

Nolan, W. E. (1989). Thumb problems of professional musicians. Medical Problems of Performing Artists, 20-24.

Norris, M. (2015). The complete guide to back rehabilitation. London: Bloomsbury Publishing Plc.

Norris, R.(1997) The musician's survival manual:a guide to preventing and treating injuries in instrumentalists, St. Louis, MO. MMB Music, Inc.

Nyman, T. W. (2007). Work postures and neck-shoulder pain among orchestra musicians. American Journal of Industrial Medicine, 370-376.

Oatis, C. A. (2009). Kinesiology: the mechanics & pathomechanics of human movement. Baltimore: Lippincott Williams & Wilkins.

Ohlendorf, D. E. (2017). Fit to play: posture and seating positionanalysiswith professional musicians-a study protocal. Journal of Occupational Medicine and Toxicology, 12(5), 1-14.

Okoshi, K. M. (2017). Musical instrument-associated health issues and their management. J. Exp. Med., 49-56.

Ormand, F. (2017). Fundamentals for fine clarinet playing. Eudora, KS: Fred Ormand.

Parncutt, R., McPherson, G.E. (2002) The science and psychology of music performance: creative strategies for teaching and learning. New York: Oxford University Press

147

Paull, B., Harrison, C. (1997) The athletic musician: a guide to playing without pain. Lanham, MD. The Scarecrow Press

Pavilack, L. A. (2016). Pain-free posture handbook: 40 dynamic easy exercises to look and feel your best. Berkeley, CA: Althea Press.

Peng, T. P. (2015). Mechanics of circular breathing in wind musicians using cine magnetic resonance imaging techniques. The Laryngoscope, 412-418.

Peterson-Kendall, F. K.-M.-P.-R. (2005). Muscles testing and function with posture and pain. Philadelphia: Lippincott Williams & Wilkins.

Petrous part of the temporal bone. (2017, April 4). Retrieved December 8, 2017, from Wickipedia: https://en.wikipedia.org/wiki/Petrous_part_of_the_temporal_bone

Phil, D. (2014, July 14). Muscle imbalances verified in upper crossed syndrome patients. Retrieved from Muscle Imbalance Syndromes: http://www.muscleimbalancesyndromes.com/janda-syndromes/upper-crossed- syndrome/

Quarrier, N. (2005). Proper chairs for music programs; sitting, playing, and staying healthy. Retrieved January 26, 2018, from The University of Sydney Sound Practice Project: http://sydney.edu.au/medicine/sound-practice/activities/wind-brass-study/Wenger- Nota-White-Paper.pdf

Rietveld, A. B. (2013). Some thoughts on the prevention of complaints in musicians and dancers. Clin Rheumatology, 32, 449-452.

Rolf, I. (1989). Rolfing: reestablishing the natural alignment and structural integration of the human body for vitality and well-being. Rochester, VT: Healing Arts Publications.

Rolf, S. (2010). A hand position training tool for clarinet. not published. Billings, Montana, United States of America: not published.

Schlinger, M. (2006). Feldenkrais method, Alexander technique, and Yoga--body awareness therapy in the performing arts. Physical Medicine and Rehabilitation Clinics of North America, 865-875.

Schuele, S. L. (2003). Focal dystonia in wind instrumentalists. Medical Problems of Performing Artists, 15-20.

Shimada, K. G. (1989). Morphology of the pterygomandibular raphe in human fetuses and adults. The Anatomical Record, 117-122.

Shoebridge, A. S. (2017). Minding the body: An interdisciplinary theory of optimal posture for musicians. Psychology of Music, 821-838.

Silva, A. G. (2013). Does forward head posture affect postural control in human healthy volunteers? Gait & Posture, 352-353.

148

Sousa, C. M. (2017). Playing-related musculoskeletal disorders of professional orchestra musicians from the north of Portugal: comparing string and wind musicians. Acta Med Port, 302-306.

Stein, K. (n.d.). The art of clarinet playing. Van Nuys, CA: Alfred.

Studyblue. (2018). Muscles of the head and neck. Retrieved February 3, 2018, from Studyblue: https://www.studyblue.com/notes/note/n/muscles-of-the-head-and- neck/deck/8443730

Swift, S. (1985). Centered riding. New York: St. Martin's Press.

Watson, A. H. (2009). Th biology of musical performance and performance-related injury. Lanham, MD: Scarecrow Press, Inc.

Wells, C. K. (2012). Defining Pilates exercise: a systematic review. Complementary Therapies in Medicine, 252-262.

Wenger Corporation. (2018). Wenger musician chair. Retrieved January 26, 2018, from Wenger: https://www.wengercorp.com/chairs/musician-chair.php

White, E. R. (1974). Electromyographic analysis of embouchure muscle function in trumpet playing. Journal of Research in Music Education, 299.

Wilson, T. A. (2001). Respiratory effects of the external and internal intercostal muscles in humans. Journal of Physiology, 319-330.

Wormsley, L. M. (2005). Sitting posture of subjects with postural backache. J Manipulative Physiol Ther, 213-218.

Young, K. (2014). Clarinet thumb-rest function: the pedagogy of positioning and electromyography evidence. Retrieved 12 19, 2017, from LSU Digital Commons: http://digitalcommons.lsu.edu/gradschool_dissertations-691

Zaza, C. C. (1998). The meaning of playing-related musculoskeletal disorders to classical musicians. Soc Sci Med, 2013-2023.

Zaza, C. F. (1997).M usicians' playing-related musculoskeletal disorders: an examination of risk factors. American Journal of Industrial Medicine, 292-300.

149

Appendix A: Anatomical Directions, Planes, and Landmarks

Figure 89. Directional References Used In Anatomical Descriptions

(2018 https://en.wikipedia.org/wiki/Anatomical_terms_of_location Accessed February 24, 2018 )

150

Figure 90. Surface Anatomy and Landmarks of the Human Body (Rawling, L. & Bathe, L., 1913. Public domain.)

151

Figure 91. Anatomical Planes of the Human Body

(https://training.seer.cancer.gov/anatomy/body/terminology.html Accessed 11February, 2018. Public Domain)

152

Appendix B: Summary Chart of Muscles Relevant to the Clarinetist

Table 1. Table of Skeletal Muscles

Name Origin Insertion Action Comments Muscles of the Head and Neck Muscles of the Embouchure Orbicularis maxilla and lips and skin draws lips complex oris mandible around lips together, pulls muscle; fibers corners of lips from other inward, purses facial muscles lips or draws join and or lips against insert into it teeth Depressor body of skin of corner pulls corners anguli oris mandible of mouth; of mouth some fibers downward merge with upper part of orbicularis oris Depressor front of skin and pulls lower lip fibers pass labii mandible mucosa of downward through inferioris lower lip inferior part of orbicularis oris Mentalis front of skin of chin draws skin of aids in forcing mandible lower lip lower lip upward; against gums protracts lower and teeth lip Risorius subcutaneous skin and draws corner minor tissue mucosa of of mouth contributor to overlying lateral corner laterally elevating parotid of mouth corner of mouth Zygomaticus posterior skin and pulls corner of major surface of mucosa of mouth laterally zygoma corner of and upward mouth

153

Name Origin Insertion Action Comments Zygomaticus posterior upper lip, just pulls corner of major minor surface of medial to mouth laterally contributor to zygoma insertion of and upward upward Zygomaticus movement of major lip Levator labii infraorbital skin of lateral pulls upper lip some fibers superoris margin of half of upper superiorly merge with maxilla ip orbicularis oris Levator labii frontal process skin and lifts nasal ala also widens superioris of maxilla muscles of and lifts upper naris alaque nasi along nose upper lip lip Levator canine fossa skin of corner lifts corner of anguli oris of maxilla of mouth; lip some fibers extend around corner of mouth to blend with inferior portion of orbicularis oris Buccinator posterior becomes a limited surface of continuous number of alveolar with fibers of fibers attach to process of orbicularis oris the skin maxilla and in both lips; medial surface other fibers of mandible pass through just the orbicularis posteromedial oris to to last molar attaching to mucosa of lips

Muscles of Mastication Masseter lower border lateral surface closure of jaw; forceful and and of ramus of deviates jaw to closure posterior mandible from opposite side possible in surfaces of coronoid combination zygomatic process to with medial arch angle pterygoid and temporalis

Temporalis temporal fossa medial side of forceful jaw on side of ramus and closure; skull coronoid deviates jaw to process; upper same side border of coronoid process; anterior ramus

154

Name Origin Insertion Action Comments Medial lateral plate of medial surface forceful jaw forms sling pterygoid pterygoid of ramus closure; with masseter deviates jaw to m opposite side Lateral inferior articular protracts pterygoid surface capsule and mandible sphenoid disc of TMJ Hyoid Musculature Suprahyoid Muscles – Sometimes referred to as extrinsic muscles of larynx digastric mastoid hyoid bone depresses bellies join at posterior process of mandible, the hyoid bone belly temporal bone elevates hyoid, pulls hyoid anteriorly digastric posterior hyoid bone same as when hyoid is anterior belly surface of posterior belly fixed, it mandible in depresses midline mandible stylohyoid styloid hyoid bone elevates probably process of hypoid and active in temporal bone pulls hyoid swallowing posteriorly and speech mylohyoid posterior hyoid bone elevates floor forms floor of surface of of mouth and mouth; active mandible in hyoid; in wide mouth midline depresses opening mandible geniohyoid posterior anterior elevates and lies deep to surface of surface of pulls hyoid (above) mandibular hyoid bone anteriorly; mylohyoid symphysis depresses mandible Infrahyoid Muscles sternohyoid posterior inferior aspect depresses surfaces of of hyoid bone hyoid bone; manubrium stabilizes sternum and hyoid medial clavicle thyrohyoid thyroid inferior aspect depresses a continuation cartilage of hyoid bone hyoid bone of the and larynx; sternothyroid stabilizes muscle hyoid

155

Name Origin Insertion Action Comments omohyoid superior inferior aspect depresses two bellies border of of hyoid bone hyoid bone; join via an scapula (superior stabilizes intermediary (inferior belly) belly) hyoid bone tendon at base of neck posterior to the sternocleidoma stoid m. sternothyroid posterior inferior aspect depresses surface of of thyroid larynx sternum and cartilage cartilage of first rib Palatal and Pharyngeal Muscles superior sphenoid joins fibers of constricts and pharyngeal bone, contralateral narrows constrictor mandible, superior pharynx posterolateral constrictor aspect of tongue middle hyoid bone joins median constricts and median pharyngeal and stylohyoid pharyngeal narrows pharyngeal constrictor ligament raphe pharynx raphe joins both middle constrictors together inferior thyroid and joins median constricts and median pharyngeal cricoid pharyngeal narrows pharyngeal constrictor cartilages raphe pharynx raphe joins both inferior constrictors together stylopharyng styloid mucosal lining elevates eus process of of pharynx, pharynx and temporal bone middle larynx pharyngeal constrictor, thyroid cartilage salpingophar cartilage of blends with elevates yn-geus auditory tube stylopharynge pharynx and us larynx

156

Name Origin Insertion Action Comments Muscles of the Neck Extensors of the Head and Neck Suboccipital Muscles rectus capitus posterior arch occipital bone unilateral: posterior of C1 (atlas) ipsilateral minor rotation; bilateral: extension of head on atlas rectus capitus spinous occipital bone unilateral: posterior process of C2 ipsilateral major (axis) rotation, lateral bending; bilateral: extension of head on atlas inferior spinous inferior unilateral: oblique process of C2 surface of ipsilateral (axis) transverse rotation process of C1 (atlas) superior transverse posterior unilateral: oblique process C1 aspect of ipsilateral (atlas) occipital bone rotation; bilateral: extension of head on atlas Transversospinal Muscles multifidus spinous transverseproc unilateral:later processes C2- esses and al flexion, C7 articular contralateral processes C7- rotation; T2 bilateral: extension of spine Semispinalis Plane semispinalis transverse occipital bone unilateral: capitis processes C7 extension with & T1-T6 slight lsteral flexion; bilateral: extension of head & neck, accentuation of cervical lordosis

157

Name Origin Insertion Action Comments semispinalis transverse spinous unilateral: cervicis processes T1- processes C2- extension T6 C5 cervical spine, lateral flexion lover cervical spine; bilateral: extension lower cervical spine

Splenius and Levator Scapulae Plane splenius inferior lateral aspect unilateral: capitis mastoid of mastoid & extension of process, occipital bone head and C ligamentum spine,lateral nuchae & flexion of head spinous and C spine, processes T1- ipsilateral T6 rotation; bilateral: extension of head & C spine, accentuation of cervical lordosis splenius inferior transverse unilateral: cervicis mastoid processes C1- extension of process, C4 (posterior head and C ligamentum to levator spine,lateral nuchae & scapulae) flexion of head spinous and C spine, processes T1- ipsilateral T6 rotation; bilateral: extension of head & C spine, accentuation of cervical lordosis

158

Name Origin Insertion Action Comments levator transverse superior part unilateral: with scapulae processes C1- of medial scapula fixed, C4 border of extension C scapula spine, flexion of C spine, ipsilateral rotation of C spine; with C spine fixed, scapular elevationdown ward rotation & adduction; bilateral: extension of C spine with fixed scapula, accentuation of cervical lordosis longissimus transverse mastoid unilateral:exte capitis processes of process nsion & lateral ceervical & flexion of the superior head, thoracic ipsilateral vertebrae rotation of head & spine; bilateral: extensiion of head

Superficial Plane trapezius external lateral third of unilateral: anchors occipital clavicle, spine scapular shoulder girdle protuberence,l of scapula, & elevation, to axial igamentum acromion depression, skeleton; nuchae, adduction, & primary spinous upward responsibility processes C7- rotation; is movement T12 unilateral with of shoulder scapula fixed: girdle; also lateral flexion participates in & contralateral movement of rotation of C arm spine; bilateral: extension of head, increase lordosis of C spine

159

Name Origin Insertion Action Comments Flexors of the Head and Neck sternocleido- lateral surface sternal head: unilateral: mastoid of mastoid anterior extension of (SCM) process, surface of head, lateral superior manubrium flexion of nuchal line of sternum; head, occipital bone clavicular contralateral surface, rotation of superior head and neck; surface of bilateral: medial third of flexion of head clavicle and C spine longus basilar aspect transverse unilateral: capitis of occipital processes, C1- lateral flexion bone C3 and ipsilateral rotation of spine; bilateral: flexion of C spine rectus capitis base of skull anterolateral unilateral: very short mm anterior just anterior to surface of C1 lateral flexion with limited occipital (atlas) of C spine; force condyles bilateral: production flexion of head rectus capitis occipital bone transverse unilateral: very short mm lateralis jugular process of C1 lateral flexion with limited process (atlas) of C spine; force bilateral: production flexion of head anterior transverse first rib, unilateral: scalene processes C3- superior lateral flexion C6 surface and contralateral rotation of C spine, elevation of ribs; bilateral: C spine flexion middle transverse first rib, unilateral: scalene processes of superior lateral flexion C4-C6 surface and contralateral rotation of C spine, elevation of ribs; bilateral: C spine flexion

160

Name Origin Insertion Action Comments posterior transverse outer border of unilateral: scalene processe of second rib lateral flexion C4-C6 and contralateral rotation of C spine, elevation of ribs; bilateral: C spine flexion

Muscles of the Shoulder Axioscapular and Axioclavicular Muscles trapezius occipital posteriolateral upper a very large protuberrance clavicle, trapezius:scapu muscle, the and medial medial aspect lar elevation, trapezius is superior of acromion, adduction & considered to nuchal line, tubercle and upper rotation, have three spinous superior lip of elevation of parts: upper, processes and scapular spine sternoclavicular middle, and supraspinous joint; middle: inferior--with ligaments of scapular fibers of each

C7-T12, & elevation & part oriented in ligamentum adduction; different nuchae lower: scapular directions, adduction, each part has a depression, & different set of upward rotation functions serratus anterolateral medial border scapular anterior surfaces and of anterior elevation, superior surface of upward borders of 8- scapula rotation, & 10 uppermost abduction ribs & their intervening intercostal mm levator transverse medial border scapular scapulae processes C1- of scapula adduction, C4 between elevation, & scapular spine downward and superior rotation angle rhomboid spines & medial border scapular major supraspinous of scapula adduction, ligaments of between elevation, & T2-T5 scapular spine downward and inferior rotation angle

161

Name Origin Insertion Action Comments rhomboid spinous medial aspect scapular minor processes of of scapula at adduction, C7 & T1, & level of elevation, & nuchal scapular spine downward ligament rotation pectoralis anterior & medial & scapular minor superior superior anterior tilt, borders of surfaces of elevation, 3rd--5th ribs scapular depression, coronoid adductiion, process abduction, upward rotation subclavius junction of 1st inferior sternoclavicula rib with 1st surface mid- r joint chondral third of depression cartilage clavicle sternocleido lateral surface manubrium sternoclavicula other functions mas- tiod of mastoid sternum & r joint are listed in (SCM) process& medial third of elevation this muscle’s lateral aspect clavicle entry as a of occipital flexor of the superior neck nuchal line Scapulohumeral Muscles deltoid anterosuperior deltoid anterior a multipennate aspects of tuberosity of deltoid:shoulde muscle, its lateral third of humerus r flexion, fibers run clavicle, abduction, obliquely from superolateral medial multiple surface of rotation, & directions (in acromion, & horizontal this case 3) to crest of adduction; insert into a scapular spine middle deltoid: single tendon shoulder abduction, flexion, & extension; posterior deltoid: shoulder extension, abduction, adduction, lateral rotation, & horizontal abduction

162

Name Origin Insertion Action Comments supraspinatus medial two glenohumeral shoulder muscle of the thirds of joint capsule, abduction, rotator cuff supraspinous & greater lateral rotation, fossa on tubercle of medial posterior aspect humerus rotation, & of scapula stabilization infraspinatus medial two glenohumeral shoulder muscle of the thirds of joint capsule, lateral rotation, rotator cuff infraspinous & greater abduction, fossa on tubercle of horizontal posterior aspect humerus abduction, & of scapula stabilization teres minor lateral aspect glenohumeral shoulder muscle of the of posterior joint capsule, lateral rotation, rotator cuff surface of & greater adduction & scapula tubercle & stabilization shaft of humerus subscapularis subscapularis glenohumeral shoulder muscle of the fossa& lateral joint capsule& flexion, medial rotator cuff border of lesser tubercle rotation, anterior of humerus extension, surface of abduction, scapula adduction, horizontal adduction, & stabilization teres major inferior angle intertubercular shoulder of posterior groove of extension, scapula humerus adduction, & medial rotation

Axiohumeral Muscles pectoralis anteromedial intertubercular shoulder major surface of groove of medial clavicle, humerus rotation, anterior adduction, sternum from depression, & sternal notch horizontal to 6th oor 7th adduction costal cartilage, 1st - 6th or 7th costal cartilages, & aponeurosis of external oblique m

163

Name Origin Insertion Action Comments latissimus spinous intertubercular shouder may also dorsi processes of groove of extension, attach to the T6-T12spines humerus adduction, inferior angle and depression & of the scapula supraspinous medial rotation as its fibers ligaments of pass over this all lumbar structure en vertebrae and route to the sacrum via humerus thoracolumbar fascia, posterior aspect of iliac rest, & lower 3-4 ribs

Muscles of the Elbow Flexor of the Elbow biceps long head: tuberosity of elbow flexion, tendons of the brachii supraglenoid radius forearm long and short tubercle of supination, heads merge to scapula within shoulder form a single glenoid joint flexion & tendon; triceps capsule; short abduction & brachii is head: coracoid stabilization of antagonist process of shoulder joint muscle scapula Brachialis distal half of ulnar elbow flexion anterior tuberosity & surface of coronoid humerus & process medial & lateral intermuscular septae brachioradialis lateral lateral aspect elbow flexion supracondylar of distal & pronation ridge of radius, just humerus & proximal to lateral radial styloid intermuscular process septum

164

Name Origin Insertion Action Comments Elbow Extensors triceps long head: olecranon elbow antagonist brachii infraglenoid process of extension & muscle to tubercule of ulna& deep shoulder biceps brachii scapula; fascia of extension & lateral head: forearm abduction posterior aspect of humerus; medial head: posterior aspect of humerus anconeus posterior lateral surface elbow surface lateral of olecranon extension & epicondyle of process & lateral humerus posterior deviation of surface of ulna during proximal ulna pronation

Supinator Muscle supinator lateral lateral, forearm biceps brachii epicondyle of anterior, & supination is the other humerus, crest posterior primary & supinator surfaces of supinator of fossa of ulna, proximal the forearm lateral aspect radius of joint capsule Pronators pronator humeral head: both heads elbow flexion; teres common attach to forearm tendon of the lateral aspect pronation superficial of radius flexors of the approx. forearm & midway down medial shaft intermuscular septum; ulnar heaad: coronoid process of ulna pronator anteior surface anterior pulls radius quadratus of distal ulna surface of across ulna in distal radius pronation

165

Name Origin Insertion Action Comments Muscles of Forearm, Wrist, Hand, & Digits flexor carpi medial palmar wrist flexion radialis epicondyle of surfaces of and radial humerus via metacarpals to deviation; common 2nd and 3rd possibly flexor tendon digit participates in elbow flexion and forearm pronation palmaris medial superficial wrist flexion & may also longus epicondyle of surface of flexor possible function to humerus retinaculum & cupping of tighten skin of (common proximal portion hand thhe hand flexor tendon) of palmar aponeurosis flexor medial divides into flexion of PIP, possible digitorum epicondyle of tendons for MCP, & wrist; function in superficialis humerus digits 2-5, each radial & ulnar elbow flexion (common of which deviation of & extension; flexor tendon) divides at wrist possible &coronoid MCP joint; function in process of they rejoin at forearm ulna; anterior proximal end pronation & surface of of middle supination radius phalanx and insert on the palmar aspect flexor carpi medial pisiform bone, wrist flexion & possible ulnaris epicondyle of hamate bone, ulnar deviation function in humerus and 5th elbow flexion (common metacarpal & extension; flexor tendon); possible medial aspect function in of olecranon of forearm ulna & pronation & posterior supination surface of proximal ulna extensor medial base of 2nd wrist extension possible carpi radialis epicondyl of metacarpal and radial function in longus humerus deviation, & elbow (common flexor forearm extension tendon) & pronation & lateral aspect of supination supracondylar ridge and intermuscular septum,

166

Name Origin Insertion Action Comments extensor lateral dorsal surface wrist extension primary carpi radialis epicondyle of of base of 3rd and radial extensor of the brevis humerus metacarpal deviation, & wrist & (common forearm contributes flexor tendon( pronation & most to wrist supination extension strength extensor lateral sends extension of possible digitorum epicondyle individual MCP, PIP, & actions in humerus tendons to DIP; wrist forearm (common digits 2-5; extension; pronation & flexor tendon) each tendon possible wrist supinatiion & interuscular splits into 3 ulnar deviation septum parts: central inserts dorsa surface of middle phalanx; 2 lateral slips reunite & insert on dorsal surface of distal phalanx extensor lateral splits into 2 extension questionable digiti minimi epicondyle parts; lateral MCP & PIP of activity in humerus merges with 5th digit; wrist extension (common tendon of probably some & ulnar flexor tendon) extensor action in DIP deviation digitorum; extension of ulnar part 5th digit inserts MCP of digit 5 extensor & posterior metacarpal of wrist extension possible carpi ulnaris ulnar border 5th digit, & ulnar activity in medial aspect deviation forearm pronation & elbow flexion flexor proximal sends tendons flexion MCP, digitorum anterior & to insert on PIP, & DIP of profundus medial base of distal digits 2-5 surfaces ulna; phalanges of medial surface digits 2-5 coronoid process; & aponeurosis of flexor carpi ulnaris

167

Name Origin Insertion Action Comments flexor anterior palmar surface flexion of pollicis surface radius of base of thumb CMC, longus & distal phalanx MCP & IP; interosseous of thumb adduction of membrane thumb abductor posterior trapezium & thumb CMC pollicis surface of ulna base of abduction & longus & interosseous metacarpal extension; membrane & bone of thumb wrist radial distal posterior devialion, radius extension, & extension extensor posterior dorsal surface thumb MCP & pollicis radius & proximal CMC brevis interosseous phalanx of extension; membrane thumb CMC abduction; wrist flexion, extension & radial deviation extensor posterolateral dorsal surface extension of pollicis surface of base of thumb IP, longus ulna & thumb’s distal NCP, & CMC; interosseous phalanx CMC membrane adduction; thumb retropulsion; wrist radial deviation & extension extensor posterior extensor hood index finger possible action indicis surface ulna & of digit 2 MCP, PIP, & in wrisst interosseous (index finger) DIP extension; extension membrane index finger ulnar deviation Intrinsic Muscles of the Hand abductor flexor proximal palmar pollicis retinaculum; phalanx of abduction brevis scaphoid & thumb & CMC of trapezium extensorr thumb; medial bones tendos of rotation & extensor opposition of pollicis longus thumb CMC; abduction, flexion & extension of thumb MCP

168

Name Origin Insertion Action Comments flexor superficial proximal flexion, pollicis part: flexor phalanx of extension & brevis retinaculum& thumb, radial medial rotation trapezium; side; may of thumb deep portion: contribute to CMC; flexion capitate & extensor hood of thumb trapezoid bone of extensor MCP; & pollicis longus extension thumb IP opponens flexor lateral half of opposition of pollicis retinaculum & entire thumb thumb CMC trapezium metacarpal adductor anterior proximal adduction & possible action pollicis surfaces of phalanx of flexion of in adduction of metacarpals 2, thumb & thumb CMC; thumb MCP 3 & 4; capitate extensor hood flexion of bone; synovial of extensor thumb MCP; sheath of pollicis longus extension of flexor carpi thumb IP radialis; transverse head attaches to 3rd metacarpal abductor pisiform bone, ulnar aspect abduction & digiti minimi pisohamate base of flexion of 5th ligament, & proximal digit MCP tendon of phalanx of 5th joint; flexion flexor carpi digit (little 5th digit CMC; ulnaris finger) extension 5th digit PIP & DIP flexor digiti flexor ulnar aspect of flexion & minimi retinaculum & 5th digit abduction of hook of proximal little finger hamate bone phalanx & MCP; flexion extensor hood of little finger CMC; extension of little finger PIP & DIP opponens flexor palmar surface opposition digiti minimi retinaculum & 5th metacarpal little finger hook of CMC hamate bone

169

Name Origin Insertion Action Comments dorsal each radial sides of abduction possible interossei interosseous proximal MCP’s of contribution to muscle arises phalanges of digits 2,3 & 4; adduction of sides of two index and long flexion MCP thumb CMC adjacent fingers & ulnar joints of digits metacarpal side of 2,3, & 4; bones proximal extension PIP phalanges of & DIP of long finger and digits 2, 3,& 4. ring finger (digits 3 & 4) palmar metacarpal each palmar abduction & interossei bones of digits interosseous flexion of 2,3, & 4 m. attaches to MCP’s of extensor hood digits 2, 3, & of its 4; extension of respective PIP & DIP of finger digits 2,3,&4 lumbricals tendons of radial side of extension PIPs possible radial flexor extensor & DIPs of deviation at digitorum expansion of digits 2-5; MCP’s of profundus digits 2 thru 5 digits 2-5 Muscles of Respiration Primary Muscles of Inspiration diaphragm posterior fibers from all lowers floor of full descent of aspect xiphoid points of thoracic the diaphragm process; costal attachment cavity; aallowable by portion:deep converge to elevates lower length of surfaces costal attach to the ribs diaphragm’s cartilages & fibrous central contractile ribs 6-12; tendon fibers is limited lumbar by abdominal portion: all 5 visceral lumbar contents; vertebrae and further medial & contraction lateral arcuate elevates lower ligaments ribs further increasing thoracic volume external originates inserts on the draws lower acting as a intercostals from the rib rib below rib up & group, they lift above,runs outward; and expand the downward and inspiration circumference forward of the thorax

170

Name Origin Insertion Action Comments Primary Muscles of Expiration internal origin is rib inserts on rib draws upper intercostals above & runs below rib downward. posteroinferio Expiration rly to rib velow external anterior iliac crest, when pelvis is bilateral oblique surfaces of inguinal fixed, it lowers contraction ribs 5-12 ligament, & ribs and causes flexion abdominal contributes to of the trunk; aponeurosis expiration unilateral contributing to contraction linea alba causes side bending rectus crest & xiphoid pulls thorax lies within abdominus symphysis of process and toward pelvis rectus sheath pubic bones cartilages of formed by ribs 5-7 aponeuroses formed by external oblique, internal oblique & transversis abdominiis internl belwo, iliac abdominal unilateral assists in oblique crest & aponeurosis contraction: flexion of inguinal side bending & trunk ligament: ipsilateral posterior, rotation of lumbodorsal spine; if pelvis fascia; above, is fixed, it ribs 9-12 lowers ribs & pulls ribs backwards,& compresses abdomen assisting in expiration transversus iliac crest, & inner surfaces decreases abdominis inguinal of ribs 6-12 diameter of ligament, (interdigitates abdomen; lumbar with fibers of increases vertebrae diaphragm) & lumbar linea alba lordosis; anteriorly expiration

171

Name Origin Insertion Action Comments quadratus posterior iliac rib 12, & side bending of lumborum crest transverse lumbar spine processes L1- & rib cage; L5 expiration; raises pelvis if ribs & spine are fixed Accessory Muscles of Respiration sternocleidomastoid sternum & elevates mastoid process of clavicle sternum & (SCM) temporal bone clavicle, thus assists in inspiration; unilateral contraction: contralateral rotation of head; bilateral: extension of head accentuation of cervical lordosis scalenes anterior: anterior & elevate 1st & thought to act transverse middle: 2nd ribs; even in quiet processes C-3- anterior aspect active in respiration C-6; middle: of 1st rib; inspiration; C-2--C-7: posterior part: unilateral posterior: C-4- lateral surface contraction C-6 of 2nd rib with fixed ribs: side bending of C-spine interchondral Extends from sternum elevation of may function portion of rib angles anteriorly sternum, in forced internal posteriorly inspiration inspiration intercostals and occupies interchondral spaces pectoralis anterior lateral aspect if shouder Suspends the major medial of humerus fixed, inferior chest clavicle fibers &sternum & participate in costal inspiration; if cartilages shouder fixed & arm is flexed, all fibers participate in inspiration

172

Name Origin Insertion Action Comments pectoralis anteriorly, ribs coronoid if ribs fixed, assists in minor 3-5 process of pulls scapula inspiration scapula forward & when scapula down; if is fixed scapula fixed, elevates ribs serratus upper 10 ribs entire medial if scapula participates in anterior border of fixed, elevates inspiration scapula middle ribs; if when ribs are ribs fixed, fixed flattens scapula against ribcage; abduction & upward rotation of scapula subclavian bottom of 1st rib elevation of clavicle (chondral 1st rib portion) transverse posterior of cartilages of llowers ribs 2- assists in thoracis lower sternum ribs 2-6 6 expiration & xiphoid trapezius spinous scapular spine adduction, a very large processes C2- & lateral elevation muscle; action T12 clavicle & &upward depends upon acromion rotation of which fibers scapula; are contracting depression &upward rotation of scapula; stabilizes ribcage levator transverse scapula, elevates and scapulae processes C1- medial border rotates scapula C4 inferiorly when neck fixed; when scapula is fixed, unilater contraction causes sidebending of neck & bilateral causes neck extension

173

Name Origin Insertion Action Comments rhomboideus C7 & T1-T4 medial border adduction & major & scapula downward minor rotation scapula with slight elevation of thorax serratus spinous ribs 1-5 elevates ribs posterior processes C7- assisting in superior T3 inspiration spinalis spinous spinous spinal one of the thoracis processes T1- processes T11- extension in erector spinae T10 L2 thoracic muscles; region; assists important in inspiration postural muscles longissimus transverse thoracic extension of one of the thoracis processes L1- transverse spine; assist in three erector L5 processes& inspiration spinae posterior muscles; aspects of ribs important 9 & 10 postural contributor intercostalis iliac crest via lower ribs extension of one of the lumborum lumbar fascia spine; assist in three erector inspiration spinae muscles; important postural contributor Levatores transverse tubercle of rib rotation of expansion of costorum processes of 1 or 2 levels spine or back during thoracic below elevation of inspiration vertebrae ribs subcostals internal internal depresses antagonists to posterior aspects of ribs lower ribs; levator aspects of two to three function in costorum mm lower six ribs levels below. expiration latissimus iliac crest, humerus on extension, contributes to dorsi sacrum, bicipital adduction, forced thoracolumbar groove medial rotation expiration fascia, spinous of processes T7- arm;extension T12& lumbar spine posterior (bilateral surfaces ribs contraction; 9-12 stabilizes trunk;

174

Name Origin Insertion Action Comments serratus spinous ribs 9-12 depresses ribs antagonistic posterior processesT12- 9-12, assists in muscle of inferior L2 expiration serratus posterior superior

175

Appendix C: Spinal Nerves and Nerves of the Upper Extremity

176

177

Segmental innervation of right upper extremity, anterior

view

Segmental innervation of upper extremity, posterior

178

179

180

181