Alignment Tips and Modifications for Carpal Tunnel Syndrome
. . . and other sources of hand/wrist discomfort
by Amber Burke
Editor's note: The below are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a health professional. Yoga teachers should remain within their scope of practice: This means not attempting to diagnose, treat, or offer medical advice to students.
Pain or sensitivity in the wrists or hands can make it difficult to bear weight in the hands when doing yoga postures, and it can make certain mudras (yogic hand gestures) less than meditative. To tailor any type of yoga practice for carpal tunnel syndrome and other wrist or hand issues, students and their teachers will first need to understand what could be causing the irritation and then adhere to certain do’s and don’ts that respect individual needs and limits.
While wrist and hand pain could stem from several different problems that should be diagnosed by a medical professional, Bill Reif, a physical therapist and author of The Back Pain Secret: The Real Cause of Women’s Back Pain and How to Treat It, says that when it comes to yoga, “Those with many different wrist and hand diagnoses can benefit from similar alignment and modifications.”
Potential Sources of Hand and Wrist Pain
Carpal tunnel syndrome (CTS) is a repetitive motion injury common in those who work on computers or assembly lines or with vibrating tools, or who continually press the wrist or heel of their hands into hard surfaces (like a steering wheel). CTS occurs when the median nerve is compressed within the carpal tunnel, a small passage on the palm side of the wrist. Symptoms typically start with numbness or tingling in the hands—usually the thumb, index, and middle finger—but these sensations may, over time, travel along the affected arm.
While estimates of the prevalence of carpal tunnel syndrome vary, it seems to be common in the general population. And there are factors other than repetitive labor that seem to increase the risk. There is, for instance, a strong correlation between CTS and larger body sizes. It is also more common in women than in men, possibly because the carpal tunnel itself tends to be narrower in women. Arthritis, glandular disorders, and wrist trauma seem to be contributing factors to CTS. And while women over 45 experience the most CTS, Reif adds that “It is common in the third trimester of pregnancy due to the swelling that often occurs throughout the arms.”
However, the median nerve involved in CTS is one of three main nerves in the arm. Other wrist issues may arise from the compression of other nerves that run through the wrists, or “All three nerves may be involved,” Reif says.
The ulnar nerve, which runs from the side of your neck (the brachial plexus) down into your hand, can be compressed (at the collarbone, elbow, or in Guyon’s canal in the wrist) as a result of repeatedly bending the elbow, leaning on the elbow, or injuring it. Ulnar nerve entrapment is associated with pain and tingling in the hands and/or the pinky finger and ring finger.
As a result of overuse, injury, or repeated pronation and supination (that is, turning) of the hand and wrist, the radial nerve (running from the inside of the shoulder, or brachial plexus, to the thumb side of the hand) can also be compressed along its path, underneath the muscles that supinate or extend the wrists (the supinator and the extensor carpi radialis brevis). Radial tunnel syndrome may cause pain in the forearm and weakness in the wrist.
Other sources of wrist and hand pain include:
• tendinitis (or, if chronic,“tendinosis”) in the hand, wrist, or elbow;
• De Quervain's tenosynovitis (swelling and inflammation of the tendons on the thumb side of the wrists); “trigger finger” or “trigger thumb” (a result of the tendons thickening or swelling);
• Dupuytren’s contracture (a thickening of tissue beneath the skin on the palm side of the hand, which restricts finger motion); and
• Ganglion cysts (bumps filled with clear, jellylike fluid). “When large and close enough to a nerve, a Ganglion cyst may cause compression similar to CTS,” Reif says, adding that “Both rheumatoid and osteoarthritis can contribute to hand and wrist pain often associated with hand nodules that may compress nerves.”
Medical treatment for many of these diagnoses may include rest, massage, splinting, stretching, anti-inflammatory medicines, and steroids. In severe cases, surgery may be needed. With any of these problems, it’s important to steer clear of the wrist positions that cause pain. It’s also important to practice maintaining a neutral wrist position (explained below), which is most likely to alleviate the pressure on the affected nerves and tissues.
Understanding Neutral Wrist Alignment
“Keeping a neutral wrist and avoiding placing pressure on a flexed or extended wrist are near-universal recommendations for those with many wrist- and hand-related ailments,” Reif explains.
A neutral wrist position is one in which the wrist is best supported by its musculature and its nerves are not being compressed. The line from the forearm to the back of the hand should be smooth—i.e., with no crease in the wrist. This is the hand position called for in poses such as warrior II and triangle.
By contrast, an extended wrist brings the fingertips toward the back of the forearm. If you are holding your arm straight out in front of you, you can extend your wrist by turning your palm to face away from you and pointing your fingers toward the ceiling, as if gesturing “stop.” (Pointing your fingers down, with your palm still facing away from you, is extension with forearm rotation.) The wrists are extended in yoga poses like tabletop, upward-facing bow, and peacock. The hand positions in namaste and reverse namaste (prayer and reverse prayer) also involve wrist extension.
A flexed wrist draws the fingertips toward the underside of the forearm. If your arm is straight out in front of you, turning your palm toward you and pointing your fingers down flexes the wrist. (Turning your fingers upward, with your palm still facing you, is wrist flexion with forearm rotation.) Wrist flexion is not common in yoga (which in itself may contribute to muscular imbalances in the wrist. See our strengthening practice for a wrist flexion exercise).
Tips for Practicing Yoga With Hand and Wrist Issues
In any type of yoga class, then, there is one clear “do” recommended for those with hand and wrist issues: Keep a neutral wrist. There are two big “don’ts”: Don’t flex or extend the wrists to the point of pain, and do not place weight on the hands while the wrists are not in neutral position. That may mean:
1. Skipping Extended-Wrist Poses
One way to keep practice accessible if you have wrist issues is to refrain from poses that call for the wrists to be extended and the hands to bear weight—foregoing the poses of the vinyasa, and focusing instead on standing, seated, prone, and supine poses in which the wrists are in neutral and there is no pressure on the hands.
2. Modifying Aggravating Poses to Create a Neutral Wrist
Some potentially aggravating poses can be modified according to the suggestions under “Modifications” below in order to keep the wrists in a neutral position.
3. Paying Attention to the Wrists in All Poses—Even Neutral-Wrist Poses
When practicing any neutral-wrist pose, it is important to make sure that your wrists are actually in neutral. Notice, for example, if your wrists habitually deviate from neutral, often into extension. (For some people, the inability to keep a neutral wrist may precede wrist problems.) You can begin to retrain your wrists by bringing your awareness to the wrists in poses like warrior II, in which your wrists and forearms ideally press down into an imaginary tabletop; and even in eagle pose, pressing the backs of the hands together, rather than the palms, might best facilitate neutral-wrist alignment.
Modifications for Hand or Wrist Issues
When opening or closing practice, instead of bringing the hands together in “prayer” or “namaste” at the heart center, which requires full extension of the wrists, try these options:
Option 1: Bring your palms together, but lift them to your forehead (as you would before a bow and “namaste”), working to create a continuous line between your forearms and the back of your hands.
Option 2: Take bear grip. For this kundalini mudra, said to stimulate the anahata chakra, hold your left hand in front of your heart, palm forward, thumb down. Place your right hand over your left so that your palms are facing each other, curl your fingers together loosely, and pull gently.
Often, teachers instruct pyramid pose with the hands in reverse namaste: hands behind the back, palms together, fingers pointing toward the ceiling. This will not be tolerable for many of those with wrist problems.
Option 1: Press your fists together, knuckles against knuckles, behind your back.
Option 2: Encircle one wrist with the opposite hand.
Tabletop—With Neutral Wrists
From hands and knees, plank, or similar poses, students can take the pressure off their wrists by creating neutral wrists in a variety of ways (based on their needs), such as coming down onto the forearms, making fists, or holding dumbbells.
Option 1A: From hands and knees, come down to your forearms, positioning your shoulders above your elbows and working to keep your forearms parallel.
Option 1B: Use blocks on their flattest settings to support your forearms here in order to make forearm tabletop feel more like a regular tabletop.
Option 2: Support yourself on your fists instead of on your palms: Make fists with the thumbs facing forward or turned out slightly to encourage more external rotation of the shoulders. Note that it is still possible to extend the wrists while making fists: Monitor your wrist position to make sure the path from your forearm to the back of your hand is smooth. Avoid clenching your fists, keeping them as relaxed as possible.
Option 3: Hold on to dumbbells (with as loose a grip as possible), keeping neutral wrists.
Tabletop—With Less Wrist Extension
For those whose wrist or hand discomfort is less severe or is improving, some extension may be tolerable.
Option 1: Place a wedge at the front of your yoga mat (so that the thinnest part of the wedge is pointing toward the top edge of the mat), and come to hands and knees, placing your hands facing downward on the slant of the wedge. (If you don’t have a wedge, you can place the folded front edge of your mat or a folded blanket under the heels of your hands. Since the objective of this support is to decrease wrist extension by making the heels of your hands lighter, actively slant your weight into your fingers.)
Option 2: From hands and knees, step your hands a few inches farther forward, bringing them in front of your shoulders. Note that bringing the hands in front of the shoulders often works for tabletop, but will not work in plank (when that same position requires more work and could strain the forearms, wrists, or shoulders).
Caring for Your Hands and Wrists in Daily Life
Does your wrist pain increase after working on the computer, sewing, knitting, lifting weights, chopping vegetables, gripping the steering wheel, doing home repairs, or playing an instrument?
In your daily life, just as in your yoga practice, “Avoid extremes of motion,” Reif advises. Avoid the aggravating activity, or try to move your wrist into a more neutral position and/or relax your hands if possible during that activity. “Avoid a continual, tight grasp,” says Reif, advocating that we hold loosely everything from our steering wheel to our dumbbells. Reif points out that because constant vibration, like power tools, can be especially aggravating, those with wrist or hand problems would often do well to avoid or limit their use. For good measure, be kind to your elbows: “Avoid hitting the humerus, or funny bone,” he says. “That is where the ulnar nerve is located, and this superficial nerve is easily banged.”
Reif says that if working at a computer is bothersome, “Lift your wrists or use a wrist rest that supports a neutral position, and take frequent breaks to move your arms and align your neck and shoulders.” He recommends frequently aligning the neck by bringing the ears over the shoulders, then lifting up through the crown of the head, as well as taking breaks throughout the day to do shoulder rolls and neck aligning. “Good shoulder and neck alignment matter because the nerves that run to your hands and wrists start there.”
(In addition to using the above modifications and suggestions in order to avoid aggravating your wrists and hands, you can enhance wrist and hand strength and flexibility with this therapeutic sequence.)
Photography: Andrea Killam