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The Cumulative Injury Cycle

As a musician injury coach, I have seen this cycle show up with most of my clients who are working through pain or injury. This is a concept/perspective that looks at repetitive/overuse injuries through the lens of sports science.

So let's define the cumulative injury cycle.

The injury cycle is a term created by the National Academy of Sports Medicine. It refers to a cycle of different events and stages that happen during repetitive stress injuries. Repetitive stress injuries (also referred to as overuse injuries) are very common in the musician world, and they can cause debilitating symptoms and circumstances that interfere with practice, performance, and life. In this article, I am going to dive into the different stages of the injury cycle and what one might experience at each stage.

But first - let’s get some perspective.

Playing any instrument can be considered an athletic event, with the ultimate goal of playing as effortlessly as possible. Although musicians aren’t required to be in control of extreme amounts of power and force, such as football players or olympic athletes, they are faced with many challenges including:

1. Fine motor skills involving repetitive movements over long periods of time

2. Mental endurance and stamina

3. Muscle endurance and stamina

4. Coordination and balance

5. Full capacity of the breath

6. Physical and mental responses in high-stress environments and events, often involving a high amount of adrenaline stemming from the fight or flight response

So what happens if your body isn’t able to physically manage the load of these challenges?

Enter the injury cycle.

According to the National Academy of Sports Medicine, repetitive stress injuries have different contributing factors, including:

* poor posture (I greatly resonate with the terms alignment and body organization)

* lack of daily movement

* prolonged periods of sitting (around 30-45 minutes of being in the same position will start to cause adaptations in the body)

* internal and external stressors

* poor movement patterns

* chronic mental and physical fatigue

* muscles that are repeatedly placed under stress and used in a shortened or tight position

So what is the injury cycle?

The cumulative injury cycle is the process in which a repetitive stress injury causes the body to induce a series of events in an attempt to heal itself, occurring in the following progression:

Stage 1 - Tissue Trauma

Tissue trauma is a naturally occurring event that can result from daily activity, exercise, or playing an instrument for prolonged periods of time. Essentially, tissue trauma causes micro-tears and contractive tension in a muscle. This a is healthy and normal process that helps rebuild and repair muscle in the body.

Common symptoms: general soreness, fatigue, tenderness, achiness, or DOMS (delayed onset muscle soreness - will cover this in a future blog). If there is an excessive amount of tissue trauma, you may experience extreme tenderness or pain. This stage generally lasts 24-72 hours.

Stage 2 - Inflammation

After tissue trauma has occurred, the body will start to initiate the repair and recovery process. If the body is prevented from recovering to its full capacity, or recovery continually becomes interrupted, the inflammation may occur.

This stage is often referred to by musicians as “flare ups” or “random periods of pain” usually following intense performing cycles, workshops, events, or traveling.

In my experience, the inflammation stage generally lasts anywhere from a few days to a few weeks. Symptoms can include warm sensations, soreness, fatigue, extreme tenderness, achiness, pain, and symptoms may be restrict movement. For people who live in this stage, they may have diagnosis similar to carpal tunnel, bursitis, or tendinitis.

Stage 3 - Muscle Spasms

After the inflammation stage, most of the physical symptoms will subside, but on a microscopic level, muscle spindles (tiny receptor sites that are involved in muscle activation, control, and proprioception) will start activating all the time (as a way to further protect the body from future damage), causing constant activation and shortening of the muscle. On a bigger level, think of this as trying to squeeze your bicep all day - you’ll get fatigued, cramped, and extremely tight.

Physical symptoms might include tightness, fatigue, chronic fatigue, muscle twitches, and sometimes tenderness or pain (less common). For high level performing athletes, this stage may present as a major muscle spasm (Charlie horse).

Stage 4 - Adhesions (also known as muscle knots)

Due to constant activation of the muscle spindles, adhesions will start to form. Adhesions can be described as tight nodules within the muscle tissue, essentially creating roadblocks and affecting the muscle’s ability to contract and release. Untreated muscle knots can become permanent structures that interfere with the natural human movement process. These structural changes can limit range of motion, decrease elasticity of muscles, and cause altered neuromuscular control (the next stage) as the body continues to find ways to move itself despite these limitations.

Adhesions may not be sore, or they may range from tender to painful. They may vary in size.

Stage 5 - Altered Neuromuscular Control

As your body repeats faulty movements over time with the physical adaptations that have occurred in stage 4, these patterns cause even more adaptations due to pattern overload. In this stage, the body is trying to move and regardless of limitation, adaptation, alignment, or functionality of a movement. The body is an incredible organism and will find a way to move, even if it means using muscles, joints, or suboptimal body positions that deviate from their intended functions.

Symptoms might include: Muscle fatigue, muscle cramps, losing the ability to take a full diaphragmatic breath, improper activation of certain muscle groups depending on the movement you are performing, loss of balance, loss of coordination, loss of optimum muscle function, loss of strength, etc.

Stage 6 - Muscle Imbalance

As we discussed earlier, the body is always adapting and through the progression up to stage 6, the body will adapt to the faulty mechanics of the system. This results in several different postural imbalances based upon the movements the body has adapted around. Posted below is a picture of some common postural imbalances.

This is a process and cycle that repeats and reinforces itself over time. Depending on your postural imbalances certain muscle groups will not function at a normal level, resulting in less load they are able to withstand. Thus, increasing the chance of entering different stages at an accelerated rate. Generally, the longer you are in this cycle, the more physical symptoms you may experience.

Symptoms you might experience: Any symptoms listed in stages 1-5, compressed posture, rounded shoulders, upper crossed syndrome, losing the ability to take a full diaphragmatic breath, etc. Essentially all of these imbalances decrease the function, endurance, and elasticity of certain muscles, depending on your imbalance. Therefore, if you put these already inefficient and strained muscles under load, you are more likely to cross the line into inflammation.

Final thoughts

This blog article is meant to serve as a jumping off point into this topic. There will be future blog posts around questions that may have naturally popped up.

I have worked with a wide range of musicians in different situations and almost all of them have fallen into this cycle before they come to see me. I have seen many musicians both skip steps and restart the cycle at different stages. For example, if you developed muscle knots in stage 4 and your movement is now affecting your ability to play your instrument pain-free, depending on your schedule and performance load, you may jump back to stage 1 (tissue trauma) and quickly start the cycle over again. I’ve also seen musicians live in stage 1 and 2 after making a few complete cycles. Breaking this cycle is a conversation for another time, but I hope this shined light on a different perspective. Remember that this is a naturally occurring process and the first step to prevention is education.

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In Clark, M., In Sutton, B. G., In Lucett, S., & National Academy of Sports Medicine,. (2014). NASM essentials of personal fitness training.

Clark, M., Lucett, S., & National Academy of Sports Medicine. (2011). NASM's essentials of corrective exercise training. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Berardi, J., Andrews, R., St. Pierre, B., Scott-Dixon, K., Kollias, H., & DePutter, C. (2017). The Essentials of Sport and Exercise Nutrition: Certification Manual (3rd ed.). Precision Nutrition, Inc.

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