This study investigated right shoulder injuries in collegiate and professional orchestral cellists through questionnaires and physical testing. It found that right shoulder injuries were common in both groups, with 42% of professionals and 20% of students reporting injuries. Physical testing revealed potential weaknesses in the scapular stabilizers and rotator cuff muscles as well as signs of impingement pathology. Professionals reported higher levels of pain and stiffness and students showed less scapular stability. The results indicate that shoulder injuries potentially involving impingement are prevalent in cellists and may be related to imbalances in the muscles supporting the shoulder joint from the demands of playing.

1. Purpose: Cellists sustain high levels of playing-related injury and are
particularly susceptible to right shoulder pain, yet no studies have
attempted to propose a mechanism for disease or establish possible
causal factors. The aim of this study was to investigate shoulder
injury levels and causes in two populations: professional orchestral
cellists and college-level student cellists. Methods: A questionnaire
and physical testing protocol was applied to both groups of partici-
pants, eliciting information on lifestyle, playing habits, and self-
reported injury rates as well as physical data on shoulder strength,
range of motion, and signs of injury. Results: Right shoulder
injuries are common among both student (20%) and professional
(42%) cellists and seem to be associated with measures indicating
potential lack of strength in the scapular stabilisers as well as poten-
tial degenerative changes in the rotator cuff. Significant differences
were found in the lifestyle and playing habits of the two groups.
There were increased signs of pain and stiffness in the professionals
and evidence of decreased muscular support in the students. Male
cellists showed less scapular stability; female cellists, however, gener-
ally had higher levels of pain. Conclusions: These results indicate
that injuries at the shoulder, potentially involving impingement-type
pathologies, are a common cause of pain in cellists. Based on this
study, future research for cello players could focus on targeted inter-
ventions, such as exercises for the scapular stabilisers and muscles of
the rotator cuff. Med Probl Perform Art 2012; 27(2):65–73.
2012 marks the 30th anniversary of the Medical Problems of
Performing Artists symposium, which began as a small
meeting of music medicine specialists in Aspen, Colorado.
From there it has grown into an international movement, incor-
porating all sectors of the performing arts with national organ-
isations in more than 14 countries. The movement has pro-
duced a peer-reviewed international journal, textbooks in
multiple languages, international conferences, and specialist
clinics and research centres throughout Europe and North
America. These considerable achievements mean that in the
21st century, a musician, medical professional, or administrator
faced with a playing-related medical query has access to litera-
ture and, in some cases, specialists to help inform appropriate
action. The support networks that have grown out of this
movement have meant that musicians are gradually becoming
more willing to seek professional help that is both well-
informed and passionate.
Notwithstanding these considerable achievements, one
concern that remains is the fact that high levels of playing-
related injury have remained unchanged from the earliest stud-
ies to the present day.1–3
Considering this evidence, perhaps
what is needed in the years to come is a shift of focus so that
prevention and implementation of risk-reduction measures
become central to the movement. Appropriate injury preven-
tion relies on establishing causation, which is difficult in per-
forming arts organisations where injuries result from a com-
plex interaction of instrument-specific, individual, social, and
environmental factors, and to date no research has managed to
map their interactions.1,3–7
Achieving this requires large partic-
ipant numbers (to account for instrument-specific etiologies)
and detailed physical testing, as well as data on lifestyle and
playing habits, and with the announcement of the Sound Prac-
tice study* such detailed research is now underway.
In a Sound Practice-affiliated project, the aim of this study
was to investigate high levels of right shoulder injuries
June 2012 65
AGB Award
A Study of Right Shoulder Injury in Collegiate and
Professional Orchestral Cellists:
An Investigation Using Questionnaires and Physical Assessment
Dale Rickert, BMus, Margaret Barrett, PhD, Mark Halaki, PhD, Tim Driscoll, PhD,
and Bronwen Ackermann, PhD
Dale Rickert is a doctoral candidate and Dr. Barrett is Professor and Head,
at the University of Queensland School of Music, Brisbane; Dr. Halaki is
Associate Professor, Faculty of Health Sciences, Dr. Driscoll is Associate
Professor, School of Public Health, and Dr. Ackermann is Lecturer, School
of Medical Sciences, at the University of Sydney, Sydney, Australia.
This paper has received the 2012 Alice G. Brandfonbrener Young Investi-
gator Award, in recognition of recently completed original research by a cur-
rent or recent student, granted by the Performing Arts Medicine Association.
This project was supported by a University of Queensland Research Schol-
arship and an Australian Research Council Linkage Grant (LP 0989486).
The authors report no conflicts of interest arising from this research.
Address correspondence to: Mr. Dale Rickert, 84 Hilda St., Corinda, QLD
4075, Australia. Tel +61403546482. dalerickert@gmail.com.
*Sound Practice is a joint initiative between the Australia Council for the
Arts, the Australian Research Council (ARC), the University of Sydney, and
the 8 premier state orchestras of Australia. It is a comprehensive investiga-
tion into high levels of physical and psychological illness in Australia’s pro-
fessional orchestras and amounts to AUD $1.2 million of research funding
over 5 years. The grant winners include Dr. Bronwen Ackermann (co-
author), Assoc. Prof. Tim Driscoll, and Prof. Dianna Kenny.

2. reported in both the professional and university-level cello-
playing community and how reported injuries may relate to
individual and environmental factors. This particular article
is the result of the comparative physical testing and ques-
tionnaire component from a larger PhD dissertation† and
offers perspective on the way different lifestyle and playing
habits seen in students and professionals may influence right
shoulder and general injury levels.
LITERATURE REVIEW
A number of studies into instrument-specific injury rates in
professional orchestras have found that cello players have a risk
of injury that is equal to or higher than other members of the
string family.8,9
Despite this, research into specific injuries in
the cello-playing population is limited, especially when com-
pared to similar projects focusing on the violin and viola.10–18
A breakdown of instrument injury prevalence has shown
that right shoulder injuries are present in 16% of orchestral
cellists, placing them in a similar category to other high-risk
occupations such as welders, painters and over-head ath-
letes.8,19–21
Motion capture studies on cello bowing have
found that cellists adopt similar positions of abduction and
flexion seen in these professions.20–22
Given that recent stud-
ies have found that shoulder injuries amongst musicians have
very poor rehabilitation outcomes, further investigation into
causes and prevention strategies for right shoulder injuries in
cellists is warranted.2
Because of lack of research into cello-
related injuries, currently, no model exists for possible causal
factors. The following section uses research into causes for
general shoulder dysfunction as well as motion capture stud-
ies into cello bowing to propose a theoretical physical model
for shoulder injury in cellists.
Proposing a Theoretical Model for Right Shoulder
Injuries in Cellists
Under normal conditions, both positioning of the scapula
during arm movements and balanced activation of the mus-
cles of the rotator cuff prevent the larger shoulder muscles
(such as the trapezius and deltoids) from causing the humeral
head to translate upwards and collide with the acromion.23,24
Tasks that require positions of shoulder abduction and flex-
ion and use these larger muscles (such as cello-playing) place
the rotator cuff muscles and scapular stabilisers under
increased load in order to maintain integrity of the shoulder
joint.25
If control and strength of these muscles is not suffi-
cient, this can lead to the upward movement of the humeral
head, causing painful impingement of the supraspinatus
tendon and the subacromial bursa between the acromion
and the head of the humerus.25,26
If the activity causing
impingement is not modified or the underlying muscular
imbalances are not addressed, shoulder impingement can
lead to a rotator cuff tear whereby the supraspinatus tendon
becomes frayed through abrasion against the acromion.23
This extremely painful condition is seen amongst cello play-
ers and can mark the end of a performance career [clinical
experience of authors].
Known risk factors for impingement include work tasks
that involve repetitive motion and positions that require large
amounts of shoulder abduction and flexion.20,24
EMG
research has found that precise positioning of the hand in
space and tasks that require gripping increase load on the
shoulder.20,24,27–29
All these requirements are consistent with
cello bowing movements and motion capture studies on
string bow arms suggest that this increased load in cellists
may lead to the high levels of shoulder dysfunction seen in
this population.22
Based on these findings, it seems that
impingement, caused by overloading of the scapular stabilis-
ers and rotator cuff muscles, is a possible model for shoulder
pain seen in cellists.
The above model accounts for known biomechanical
mechanisms for shoulder injury. Other individual and envi-
ronmental factors, however, should also be considered when
addressing injury causes for the upper limbs.20,30
In an
attempt to understand shoulder injury in a multifactorial
framework, this study undertook research into lifestyle and
playing habits alongside detailed physical testing that could
identify impingement or changes in strength and flexibility of
the rotator cuff and scapular muscles.
AIMS
The major goals of this research project were:
1. To identify whether differences in the lifestyles and playing
habits of professional and student cellists are related to shoulder
and general injury outcomes
2. To test for differences in shoulder health between student and
professional cellists
3. To identify potential early warning signs of shoulder dysfunction
in student cellists such as muscular imbalances or lack of scapu-
lar support
4. To measure levels of self-reported shoulder pain and levels of
impingement in the student and professional cello-playing com-
munity.
RESEARCH METHODS
This research project utilised many of the research methods,
data collection procedures, and analysis techniques devel-
oped for the Sound Practice study. The following section out-
lines the methods employed in this project. A more detailed
account of the full study methodology has been reported in
a previous paper.31
66 Medical Problems of Performing Artists
†This paper is number 3 in a set of 5 articles arising from an interdiscipli-
nary cross-institutional PhD research project administrated by the Univer-
sity of Queensland School of Music and the University of Sydney School of
Medicine. The supervisors include Prof. Margaret Barrett (UQ) and Dr.
Bronwen Ackermann (USyd). The project follows a mixed-method research
methodology and includes significant qualitative and quantitative compo-
nents. Associated researchers include Dr. Mark Halaki (statistics, program-
ming, and EMG analysis), Assoc. Prof. Tim Driscoll (epidemiology and
occupational disease), Prof. Karen Ginn (EMG research manager), and
Assoc. Prof. Suzanne Wijsman (cello advisor).

3. Ethics, Recruitment, and Research Groups
This study received ethical approval by the Human Research
Ethics Committee of the University of Sydney. Forty-seven
professional orchestral cellists from eight orchestras nation-
ally and 25 performance-major university cellists from two
teaching institutions were included in this study, as detailed
in Table 1.
Questionnaires
The questionnaires collected information on physical pro-
files, exercise and recreation, playing habits, as well as occur-
rence rates of past and present injuries.31
All questionnaires
were filled in manually by the subjects and were completed
directly before or after the physical testing component. Data
was then entered into spreadsheets, checked for errors, and
made ready for data analysis.
Physical Testing Component
In order to maximise intra- and inter-tester reliability, all
testers were physical therapists with training or experience in
music physiotherapy and musculoskeletal assessment. All
testers completed a full weekend training session on the test-
ing procedure and were monitored throughout the project by
the chief investigator (BA).
Shoulder Tests
The shoulder tests included tests for impingement, range of
motion (ROM), scapular dyskinesis, rotator cuff dysfunction,
and trigger point sensitivity. During all tests assessors noted
presence of pain, hitching or winging of the scapula, and any
evidence of decreased range of movement.
The tests for impingement included the painful arc test
and the Hawkins-Kennedy test.32,33
Deficiencies and imbal-
ances in shoulder strength for abduction, internal rotation,
and external rotation have been implicated as causative fac-
tors for shoulder impingement and were tested in this study
using isometric dynamometry.34–38
Scapulohumeral rhythm
was tested using Kibler’s lateral slide test and shoulder range
of motion was measured with Apley’s scratch tests, which
measure full range of motion in horizontal adduction, inter-
nal rotation, and external rotation.39,40
Upper trapezius trig-
ger point sensitivity was measured by applying 5 kg of pres-
sure (measured with a dynamometer) on the trigger point
approximately half-way between C7 and the acromion. Sub-
jects were asked to rate the pain on a scale from 0 to 10,
where 0 was no pain and 10 the worst pain imaginable.41,42
Finally, Beighton’s tests for hypermobility were included
because of evidence for hypermobility affecting general and
music-related injury rates.43–45
Data Analysis
Statistica V10 (Statsoft, Inc, Tulsa OK USA) and Microsoft
Excel 2007 (version 12) were used for the data analysis. Nor-
mality of the data was checked using skewness and kurtosis
measures. For all normally distributed parametric data, 2
June 2012 67
FIGURE 1. Average hours of activity undertaken by student and professional cellists in a week. Significant differences between skill groups
are marked with a star (* denotes p<0.05).
TABLE 1. Age, Gender Division, and Playing Experience for the
Professional and Student Cellists
Student x– Professional x–
Variable (n=25) (n=47)
Age (yrs) 19.24 (17–26) 42.10 (24–63)
Males/females (n) 10/15 23/24
Years played instrument 11.52 (5–15) 32.39 (14–53)

4. factor analyses of variance (ANOVA) were used with level of
skill and gender as factors. When significant interaction
ANOVA results were found, Tukey post-hoc test was used to
indicate where the differences were. When the data was not
normally distributed or the data was ordinal (non-paramet-
ric), Mann–Whitney U test was used to compare the differ-
ent skill level and gender groups. When data was categorical,
proportion’s Z-test was used to compare the groups.
To investigate the relationships between variables, Pear-
son’s correlations were run on all normally distributed para-
metric variables otherwise the non-parametric Spearman’s
rho was applied.
Throughout the paper, statistically significant results
(p<0.05) are marked with a star (*), and results approaching
significance (p<0.1) are marked with a cross (†). Significant
strength differences between males and females were not
focused upon because of known physiological differences
between men and women.
RESULTS
Playing Habits and Lifestyle Factors
Different playing habits and lifestyle factors that influence
student and professional cellists are shown in Figure 1.
Player Injury Profiles
Figure 2 shows relative injury rates for student and profes-
sional orchestral cellists. Point prevalence is shown as well as
period prevalence (over 18 months), number of current
injuries, and the relative percentage of players affected by
medical conditions or previous surgery.
Table 2 displays differences in injury frequency and sever-
ity between professionals and students and between male and
female cellists.
Table 3 shows self-reported shoulder pain across all cellists
using two definitions. The first two rows represent pain pro-
files consistent with impingement (localized pain in the
region of the acromioclavicular joint of the shoulder), and
the second two rows relate to any pain in the general shoul-
der area.
Injury site prevalence amongst all cellists is reported in
Figure 3. Shoulder pain was frequently present alongside
other disorders of the upper limbs and many cellists displayed
multiple injuries or a single injury affecting multiple sites.
Shoulders Testing Results
No statistical difference was found between the professional
and student groups for range of motion as measured by the
68 Medical Problems of Performing Artists
FIGURE 2. Relative percentage of injuries and medical problems among professional and student cellists. Significant differences between skill
groups are marked with a star (* denotes p<0.05).
TABLE 2. Injury Frequency and Severity
By Skill By Gender________________________ ________________________
Questionnaire Result Student Professional p-value Male Female p-value
Injury detail
Frequency of PRMDs 3.1 ± 2.9 3.3 ± 3.3 0.8718 2.1 ± 2.6 4.3 ± 3.3 0.0024*
Severity of PRMDs 3.9 ± 2.7 4.6 ± 2.4 0.2428 3.7 ± 2.4 4.9 ± 2.6 0.0793†
PRMD Frequency was rated from 0–10 (with 0 being never affected and 10 being constantly affected). PRMD Severity also rated from 0–10
(with 0 being no pain and 10 being the worst pain imaginable).
*p < 0.05; †p < 0.1.

5. Hawkins-Kennedy test or in any of the measures of shoulder
strength. However, for other measures of range of movement
(ROM) and muscular imbalance between the internal and
external rotators, differences were found between groups and
genders. In general, students exhibited a larger ROM than
professionals, as did females compared with males. The
results for muscular imbalance are calculated by expressing
external rotation strength (measured using dynamometry) as
a percentage of internal rotation strength (Table 4). Propor-
tion tests were also performed using more than a one-third
difference in strength between internal and external rotators
as a benchmark for imbalance. This ratio was chosen after
discussions with clinicians at the Australian Institute of
Sport about shoulder tests used to establish injury risk in
over-head athletes and swimmers.46
Of the above measures, bilateral trigger point pain was the
only measure found to be correlated with the frequency,
severity and number of current injuries for all cellists
involved in the study (Table 5).
Table 6 reports evidence of symptoms in the right and left
shoulders. Significant differences were found in the presence
of scapulohumeral dysrhythmia, scapular winging, differ-
ences in resting shoulder height, hitching of the shoulders
during testing, and the presence of pain during procedures.
Note: a positive result for Kibler’s test in positions A, B, or C,
or any increase in asymmetry between the positions is a sign
of scapulohumeral dysrhythmia.
Large numbers of professional cellists exhibited higher
left shoulders at rest, and correlations were found between
the left scapula-spine distance in Kibler’s 3 positions and
the number of hours of orchestral rehearsal undertaken by
cellists.
Hypermobility testing using Beighton’s scoring system
revealed no significant differences existed between groups
(p=0.2184), however, 12% of the student cellists were hyper-
mobile compared with 4% of the professional cellists.
DISCUSSION
Cellists sustain high levels of right shoulder injuries regard-
less of whether they are orchestral professionals or university
students. This can be seen in both self-reported pain results
(Table 3) as well as tests for right shoulder impingement
(Table 6). The physical examination and questionnaire find-
ings in this study show possible links that may help in under-
standing the results.
June 2012 69
TABLE 3. Estimates of Current Shoulder Injury Based on Type of Pain
By Skill By Gender__________________________ _______________________
Self-assessed shoulder pain Student % Professional % p-value Male % Female % p-value
Type of shoulder pain
Right impingement pain 8 24 0.0900† 21 16 0.6296
Left impingement pain 4 13 0.2123 9 11 0.7812
General right shoulder pain 20 42 0.0605† 30 39 0.4545
General left shoulder pain 24 29 0.6594 18 36 0.0968†
†p < 0.1.
FIGURE 3. Percentage of injury sites reported by all cellists with current injuries (point prevalence; results include currently uninjured sub-
jects). Data were combined because no significant difference was found between skill groups or genders.

6. For the professional cellists, both shoulders showed
marked reduction in range of motion for internal and exter-
nal rotation (Table 4), which may be an indicator of rotator
cuff tightening and could explain the increased pain and
pathology seen in this group (Table 3). Based on the com-
pressive nature of the horizontal adduction test, hitching
noted in the professionals may be a protective reflex in
response to degenerative changes in areas including the rota-
tor cuff and acromioclavicular joint. An interesting finding is
the predominance of left shoulders sitting high at rest for the
professionals (Table 6), which could be linked to high levels
of reported left shoulder pain (Figure 3). Because of signifi-
cant correlations between the number of rehearsal hours and
left scapula-spine distance (Table 7), it is possible that higher
left shoulders in professionals result from asymmetrical load-
ing during long rehearsals.5,47
For the students, scapular support (Table 6) seems to be a
significant problem with evidence of right scapular winging,
hitching, and general scapulohumeral dysrhythmia. There
were also signs of muscular imbalance in the shoulder (Table
4) with a significantly high proportion of students exhibiting
more than a one-third difference in strength between the inter-
nal and external rotators. This muscular imbalance between
internal and external rotators is known to be a risk factor for
shoulder injury in other elite performance domains and may
be linked to the shoulder injuries seen in these cellists.34–46
Grouping the results by gender produced some unex-
pected findings: male cellists showed increased signs of lack
of scapular support, while women showed far more evidence
of pain in tests for shoulder impingement as well as a trend
towards pain in the trigger point tests (Tables 4 and 6). The
correlation between trigger point pain and number of cur-
rent injuries, injury frequency, and injury severity (Table 5),
is interesting, as it may be a sign of heightened neural sensi-
tivity owing perhaps to the predominance of shoulder and
neck complaints in cellists (Figure 3).
The results of this study showed that no significant differ-
ence existed between male and female cellists for current or
past injury rates (Figure 2). Female cellists, however were
affected by injury more than twice as frequently (Table 2).
Other authors have noted higher injury rates in female musi-
cians but frequency of effect has not been examined.1,3
In the questionnaire results, the significant differences in
playing hours, rehearsal hours, and performance hours
undertaken by students and professionals may partially
account for corresponding differences in shoulder and gen-
eral injury levels. This would be consistent with previous lit-
70 Medical Problems of Performing Artists
TABLE 4. Range of Motion, Strength Ratios and Trigger Point Pain in the Shoulders of Cellists
By Skill By Gender________________________ ________________________
Physical Test Student Professional p-value Male Female p-value
Shoulder ROM (Apley’s 1 & 2—hand behind head and hand behind back tests), measured in cm
R Internal rotation (cm) 22.9 ± 5.9 27.6 ± 6.1 0.0029* 27.6 ± 5.7 24.6 ± 6.6 0.1069
R External rotation (cm) 13.3 ± 2.6 11.5 ± 2.6 0.0008* 13.2 ± 2.7 11.2 ± 2.4 0.0003*
L Internal rotation (cm) 20.8 ± 4.7 25.6 ± 5.4 0.0006* 25.5 ± 5.7 22.6 ± 5.2 0.0623†
L External rotation (cm) 13.8 ± 2.3 11.8 ± 3.0 0.0005* 13.9 ± 2.8 11.2 ± 2.4 <0.0000*
Muscular imbalance at the shoulder (external/internal)
R ER as % of R IR 74.1 ± 15.3 86.8 ± 23.0 0.0284* 84.8 ± 24.3 80.6 ± 18.9 0.4878
L ER as % of L IR 75.3 ± 16.7 83.6 ± 21.5 0.193 82 ± 21.3 79.7 ± 19.6 0.41
Muscular imbalance at the shoulder (% of cellists with an ER strength of <66% of IR strength)
R ER < 2/3 of R IR 32% 6% 0.004* 9% 21% 0.21
L ER < 2/3 of L IR 40% 17% 0.032* 21% 28% 0.495
Trapezial trigger point pain (pain scale rating from 1–10)
R trigger point 2.1 ± 2.5 2 ± 2.2 0.8436 1.4 ± 1.8 2.6 ± 2.5 0.0683†
L trigger point 2.1 ± 2.7 3 ± 4 0.1929 2.5 ± 4.6 2.9 ± 2.6 0.1563
IR=internal rotation strength, ER= external rotation strength, R= right, L= left. Note: for external rotation (Apley’s 1), a higher number cor-
responds with more range of motion (ROM), and for internal rotation (Apley’s 2), the inverse applies.
*p < 0.05; †p < 0.1.
TABLE 5. Spearman’s Correlation Between Right and Left
Trigger Point Pain and Measures of Injury
Variable n rs
value p-value
Correlation between right trigger point pain and injury
Frequency of PRMDs 67 0.2840 0.0200*
Severity of PRMDs 65 0.2420 0.0520†
No. of current injuries 69 0.3910 0.0010*
Correlation between left trigger point pain and injury
Frequency of PRMDs 67 0.2680 0.0280*
Severity of PRMDs 65 0.1820 0.1460
No. of current injuries 69 0.3740 0.0020*
PRMD Frequency was rated from 0–10 (with 0 being never affected
and 10 being constantly affected), and PRMD Severity also was
rated from 0-10 (with 0 being no pain and 10 being the worst pain
imaginable).
*p < 0.05; †p < 0.1.

7. erature that has established links between hours of playing
exposure and injury rates.48,49
Other results arising from the
questionnaires give insights into the types of environmental
and individual factors that influence student and profes-
sional musicians. Students spend the majority of their play-
ing time in personal practice, while professionals spend most
of their time in structured rehearsals and performances
where they have less control over their playing conditions.
These findings should be considered when medical profes-
sionals are implementing injury prevention or rehabilitation
programs, as modifying the playing habits and behaviours of
students may be easier, given that they have greater autonomy
over the nature and intensity of their playing.
SUMMARY
The presentation of injury site data suggests the need for
further investigation into problem areas such as the necks,
hands, arms, and lower backs of cellists. An unexpected
finding was high levels of left shoulder pain and evidence
of a link between the number of hours of rehearsal and
increased scapular asymmetry (higher left shoulder). These
results suggest that further research into the effects of long-
term asymmetrical loading on cellists is needed, and such
research would possibly need to address twisted postures
and likely changes in the positions of the pelvis and spine.
The detailed investigation into right shoulder health shows
that right shoulder pain is a major problem for profes-
sional cellists and that student cellists already show defi-
ciencies in shoulder strength and stability. Prevention
strategies aimed at addressing impingement-type shoulder
pathologies and muscular imbalances may be useful in
addressing this problem while future kinematic research
involving EMG technology would offer further evidence by
establishing the exact loads placed on cellists’ shoulders
during playing.
June 2012 71
TABLE 6. Left and Right Shoulders: Signs and Symptoms of Shoulder Dysfunction
By Skill By Gender__________________________ _______________________
Physical Test Student % Professional % p-value Male % Female % p-value
Painful arc test—pain, hitching, and ROM
R—Pain 0 9 0.1291 6 5 0.8844
L—Pain 4 7 0.6598 3 8 0.3753
R—Hitching 20 22 0.8639 21 21 0.9869
L—Hitching 12 17 0.5487 24 8 0.0576†
R—ROM limited 0 4 0.2902 3 3 0.9193
L—ROM limited 0 2 0.4578 0 3 0.3480
Hawkins-Kennedy—pain and hitching
R—Pain 52 35 0.1586 25 54 0.0139*
L—Pain 8 30 0.0343* 12 31 0.0579†
R—Hitching 57 24 0.0193* 30 33 0.7590
L—Hitching 43 21 0.1071 25 27 0.8406
Apley’s 3—Horizontal adduction test—ROM, pain, and hitching
R—Horizontal add reach 100 98 0.4578 100 97 0.3480
L—Horizontal add reach 100 98 0.4578 100 97 0.3480
R—Horizontal add pain 4 0 0.1719 0 3 0.3480
L—Horizontal add pain 0 0 0 0
R—Horizontal add hitching 8 28 0.0458* 24 18 0.5490
L—Horizontal add hitching 8 28 0.0458* 27 16 0.2371
Painful arc test—scapulohumeral rhythm, winging, and resting shoulder heights
R—Dysrhythmia 16 6 0.1897 6 13 0.3347
L—Dysrhythmia 12 2 0.0817† 3 8 0.3895
R—Winging 20 4 0.0318* 12 8 0.5274
L—Winging 4 4 0.9588 3 5 0.6571
Right shoulder higher at rest 0 6 0.1969 6 3 0.4594
Left shoulder higher at rest 0 23 0.0086* 12 18 0.4935
Kibler’s lateral slide test—scapular asymmetry. Note: this is a bilateral test
Positive position A 44 9 0.0004* 30 13 0.0688†
Positive position B 28 15 0.1810 30 10 0.0322*
Positive position C 24 26 0.8900 42 10 0.0017*
Increasing asymmetry A–B 40 30 0.3815 30 36 0.6158
Increasing asymmetry B–C 32 47 0.2250 55 31 0.0415*
Increasing asymmetry A–C 32 45 0.2963 45 36 0.4100
*p < 0.05; †p < 0.1.

8. This study has limitations based on the particular study
group (cellists) and its setting. The physical testing results are
not generalisable to other instrument groups, although the
results from the questionnaire could be applied to other set-
tings as long as cultural and situational differences are con-
sidered. This study is weakened by lack of a control study for
either of the groups, and until control groups are measured,
the influence of lifestyle and playing factors on physical
results is limited to correlations and inferences drawn from
research in other populations.
CONCLUSION
One of the great challenges in music medicine research is the
fact that musicians operate in complex and varied environ-
ments. This means that injury prevention measures must
account for instrumental-specific risk factors and appraise
injury within a multifactorial framework. The various signif-
icant findings from this study strengthen the argument for
increased research into the particular physical demands
placed on individual instrumentalist groups. Up until now,
very little information has been available on injury issues for
cellists and through this study, general injury site prevalence
has been reported as well as differences in lifestyle, playing
habits, and injury rates for student and professional cellists.
Although detailed physical testing of cellists suggests that
shoulder dysfunction is present in both groups, the types of
dysfunction appear to differ depending on the skill, gender,
and individual workload of the performer. This pioneering
study has opened up new avenues for research into injury
causation in cellists and provides a firm foundation on which
future investigations can build.
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TABLE 7. Pearson’s Correlations between Left Scapula Position
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Variable n r value p-value
Kibler’s A (L scapula-spine distance) 69 0.4451 0.0001*
Kibler’s B (L scapula-spine distance) 69 0.2916 0.0151*
Kibler’s C (L scapula-spine distance) 69 0.3870 0.0010*
*p < 0.05.

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