Physical therapist to the stars of tomorrow

September 13, 2024 -- Katy Keller Rule is the Clinical Director of Physical Therapy in the Office of Health and Counseling Services at the Juilliard School in New York City. In this video she describes the physical therapy services offered to Juilliard students. She is also my little sister and I couldn't be more proud. Here is our brief interview on 9/8/2024.

DK: Your patients are some of the world's most accomplished young musicians, dancers, and performers. What problems do they bring you?

KKR: Musicians tend to develop pain and strain around the neck, shoulder and forearm regions while the dancers typically present with foot and hip complaints. In the chronic conditions that develop and layer up over time, the site of pain is a reflection of biomechanical or movement inefficiencies. As an example, the string player might develop pain at the base of the neck and top of the left shoulder because these areas are working too hard to support the instrument due to inefficient mechanics of the rotator cuff of the shoulder and the scapulo-thoracic muscles of the back which should be providing the dynamic support in playing.

DK: You have described your patients as "small muscle athletes." Please explain.

KKR: They need tremendous dexterity and fine motor control in the hand or in the case of wind instruments, the mouth as well. They also need functional strength in the larger support musculature including the core. The performances they deliver often demand marathon-level endurance.

DK: What's the hardest part of your work?

KKR: One of the big challenges is countering expectations that there is a quick fix. These are problems that might have developed from the time they started playing an instrument at age 4 or 5 years old, but by the time I see them they are young adults. The injuries usually aren't little accidents; they are multi-factorial, multi-layered issues built up over a long and strenuous period of training. People want simple answers but those rarely exist. The sufferer might ask, should I just get a different pillow? ...as if it was one thing that produced the problem when in fact many factors over long periods of time contribute to the pain. Pain is not the problem; it is the result. Fortunately, sometimes just a small adjustment in playing posture or a modification of the interface with the instrument, or a temporary reduction in practice time or change in repertoire can lead to resolution of injury.

In the elite performance world, the issues differ from those of the recreational, amateur, or hobbyist musician. The key to recuperation is often subtle and exploratory. For the amateur, it might be a basic technique issue at fault or a clunky instrument. In contrast, for the level of musicianship we see here at Juilliard, we will assess and address alignment issues, muscle imbalances, joint impairments and also discuss pacing such as taking adequate rest breaks. Fatigue plays a big role in over-use injuries. In a conservatory setting, the musician may be playing up to 7 hours per day when you add up rehearsal, individual practice, recording sessions, auditions and performances!

On the positive side, in recent years, I've noticed that musicians have gotten a lot healthier in general. They are smarter about self-care, eat better, and have more insight into their physicality and fitness. Actually, I am in awe of the talent, drive and perfectionism of the students we get to work with. Just the other day I was working with an opera student who is preparing a lead role in Marriage of Figaro. She mentioned that she had full knowledge and recall of the 600-page score/libretto as if this were just a rudimentary expectation!

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