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.
Tennis elbow hurts: You’ll typically feel it as an ache—or if the condition is more advanced, as a sharp pain—along your forearm and elbow when gripping, lifting, or turning a doorknob, and you may cringe at the prospect of shaking anyone’s hand. You may also wonder if yoga is a good idea for you.
However, according to 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, “People with tennis elbow can certainly do yoga, as long as they avoid or modify certain stressful positions which may aggravate their elbows.”
In addition to sharing his tips below about which poses you may need to steer clear of or adapt if you have tennis elbow, Reif suggests a few therapeutic stretches you could also integrate into a yoga practice, since traditional yoga poses may not alleviate your discomfort.
But to understand what to avoid and what to do in a yoga class or home practice, it’s helpful to first know what tennis elbow is and what causes it.
The medical name for tennis elbow is lateral epicondylitis. It affects the tendons which connect to the lateral epicondyle, the outside of the elbow, as well as the muscles on the outside of your forearm that extend yourfingers, wrist, and elbow (the carpi radialis brevis and longus, extensor digitorum communis, and extensor carpi ulnaris). (In a similar manner, the less-common condition called golfer’s elbow or thrower’s elbow affects the medial epicondyle on the inside of the elbow. “Occasionally tennis players may also get medial epicondylitis from the forehand stroke,” adds Reif.)
Tennis elbow can refer to tendonitis or tendonosis: In the case of tendonitis, small tears to the elbow, wrist, and finger extensor tendons become inflamed. In the case of tendonosis, after repeated inflammation, the elbow extensor tendons degenerate though there is no current inflammation. While tendonitis is an acute injury that lasts days or weeks, tendonosis is a “recalcitrant,” or chronic injury that may last months. “It’s almost like the body’s tissue forgets how to heal,” Reif observes.
If the results of one recent population study are generalizable, there are approximately one million new cases of tennis elbow each year in the United States. Those most susceptible to getting tennis elbow, according to that same study, are between 40 and 60 years old (with women experiencing a slightly higher incidence than men).
Tennis elbow generally derives from, and is aggravated by, repetitive movements, like the tennis serve, forehand, and backhand, according to Reif. These strokes are especially risky if your racket is too stiff or heavy or the strings are too tight. Faulty technique (“leading” with your elbow, performing a backhand stroke with your wrist flexed rather than extended, or not easing up on your grip soon enough after the racquet hits the ball) can also contribute to tennis elbow.
“Tennis” elbow could be a bit of a misnomer, though: Although around fifty percent of tennis players report elbow pain, seventy-five percent of which is “true” tennis elbow, tennis players make up only about ten percent of all people with this condition.
Reif’s experience is in line with these statistics: “Most of my patients with tennis elbow didn’t get it playing tennis,” he says. “Any activity that repeatedly overwhelms the physical capacity of a tissue can result in inflammation of that tissue.” So, symptoms can result from the volleyball serve, playing instruments like the guitar, cello, or violin, scanning barcodes, weight lifting, manual labor (swinging a hammer, operating a chainsaw), cooking, gardening, or working on assembly lines. Tennis elbow can even result from playing arcade and video games. (Reif recalls an outbreak of “Pac-Man Elbow” decades back.)
In all these cases, the repetitive movement that might lead to tennis elbow is wrist and elbow extension (holding an arm straight out in front of you while making a “stop sign” with your hand) with weight applied to it. Examples of weight-bearing wrist and elbow extension include the previously mentioned backhand swing in tennis and also push-ups and the transition from to upward facing dog in yoga.
As is the case with so many repetitive injuries, alignment and muscle recruitment play a role. As Reif explains, “The better the alignment of both arms, the less strain directly applied to the elbows. So too much internal or external rotation of the shoulders may lead to too much strain on the inner or outer elbow.”
In some cases, overtaxing the extensors may be due to ineffectively recruiting the shoulder and trunk muscles during the repetitive motion cycle. “Any weakness at the shoulder or trunk can translate to irritation or injury at the elbow, because without the shoulder and the core as a base of support, the muscles around the elbow must generate the force required to hit the ball or to hammer nail after nail,” Reif asserts.
While Reif thinks it’s unlikely yoga would be the sole cause of tennis elbow, some poses can contribute to it. “If someone who’s been playing tennis, weight lifting, or painting all morning, then comes in to take a yoga class, there are a few poses that, especially if repeated, could make things worse,” says Reif.
For those whose tennis elbow (tendonitis or tendonosis) is in an acute stage—accompanied by significant pain and tenderness—there’s one major yoga “don’t,” according to Reif: “Don’t practice poses that require you to bear weight on your hands with your wrists and elbows in extension.” These include poses like tabletop, plank, upward facing dog, and downward facing dog. “Wheel would especially be problematic, because of the even greater load of body weight moving through both elbows,” says Reif. When the pain from tennis elbow has abated somewhat, some of these poses can be modified in the ways Reif suggests below.
Above all, Reif recommends that students with tennis elbow forego handstand, in which the entire weight of the body is supported by extended arms and wrists, and any arm balances where the knees are directly on top of the elbows, like crow pose and shoulder pressing pose. “As you attempt to balance your knees on your elbows, you would be applying direct pressure to both elbows and you’d be right on top of the structure that’s injured,” he points out.
Transitioning in and out of extension—from straight elbows to bent elbows, or moving from bent elbows to straight elbows—can also aggravate tennis elbow, according to Reif. “Repeatedly moving from flexion to extension [from arms bent to arms straight] places great strain on the elbow,” says Reif. So moving into and out of chaturanga, for example, can be even harder on the tendons and muscles affected by tennis elbow than holding the chaturanga itself. The common transitions from chaturanga to plank and chaturanga to upward facing dog are among the least advisable for those with tennis elbow, especially if you are repeating the transition in multiple vinyasas.
When practicing yoga with tennis elbow or adapting a sequence for a student who has it, you might simply avoid entirely poses that require weight-bearing on the hands and instead focus on standing, seated, and lying-down poses. There are also ways to modify weight-bearing poses for tennis elbow if you want to keep teaching them or exploring them in practice.
A large number of yoga poses require precisely the position that those with tennis elbow should avoid: weight-bearing extension of the wrists and elbows. Making the following modifications to poses in which the hands and arms bear weight with the wrists and elbows in extension can bring awareness to your practice and may make these poses feel better.
1. Decrease the angle of wrist extension.
Poses like tabletop, plank, and chaturanga demand 90 degrees of wrist extension, the maximum that is possible for most of us. To alleviate weight-bearing pressure through the wrists, those with mild tennis elbow may simply decrease that angle by using a yoga wedge to elevate the heels of their hands. Alternatively, in poses like tabletop, they could also move their hands slightly in front of their wrists. (Since this modification places high demands on the shoulders, it works better for tabletop than for plank.)
If your tennis elbow is more severe, make the angle of extension 0 degrees, attaining a neutral wrist by clasping dumbbells, aiming your knuckles down, and keeping your wrists flat.
You could also practice these poses on your knuckles or on your forearms. (Placing your forearms on blocks for poses like cat/cow would enable you to maintain the traditional shape of those poses.)
2. Decrease the amount of weight on your hands and arms.
When weight-bearing with your hands (using a wedge or dumbells as suggested above), minimize pressure on your hands whenever possible to spare the vulnerable structures of the elbows and wrists. For example, practice tabletop instead of plank and downward facing dog, and keep your knees down for chaturanga and upward facing dog.
To avoid placing almost any pressure on your wrists, you could also practice an upright version of these poses while standing with your hands against the wall.
3. Align your elbows carefully.
Here is Reif’s alignment advice for the elbows in poses like tabletop, plank, chaturanga, upward facing dog, and downward facing dog: “Aligning the ‘eyes of the elbows’ toward the space between the thumb and index finger will decrease strain on the elbow extensor tendons, helping to take the load off the elbows by fostering balanced muscle engagement.”
He explains that “Without the strong support of the biceps and triceps, more strain is placed upon all other muscles and tendons that cross the elbow, especially those [affected by] tennis elbow. The balance of the inner and outer elbow musculature is important for stability, and irritated tendons will definitely feel the load if they do not get ‘help’ from both sides of the elbow.”
4. Align your shoulders.
“Regularly misaligning the shoulders may lead to shoulder strain, specifically rotator cuff strain or biceps tendonitis, and in a domino-like effect place strain on the elbows,” says Reif. “Keeping the shoulders in place minimizes stress on the elbows.”
His suggestion? “In poses like plank, avoid hunching your shoulders toward your ears. Instead, hold your shoulder blades firm and steady on your back. As you lower from plank to chaturanga your shoulder blades should naturally draw together. This engagement will minimize the strain on your elbows, unloading the stress from your arm extensors to deltoids and rhomboids. The more you can unload the stress onto the stronger upper back muscles, the less you will be relying entirely on your elbows.”
Notice, too, how other factors, like the placement of your hands when lowering from plank to chaturanga, affect your shoulder alignment. According to Reif, if during this transition, instead of keeping the heels of your hands near the bottom of your rib cage, you place them up higher, under your shoulders, “This can prevent your shoulders from dropping toward the floor and your pectoral muscles from having to do nearly all the work, which can strain the fronts of the shoulder capsules and place an additional load on your elbows.”
Reif commonly offers the following three stretches to reduce the pain associated with tendonitis. However, those who have been diagnosed with tendonosis or whose tennis elbow has persisted for a year or more, should reserve such exercises until after seeking treatment from a qualified doctor or physical therapist.
Once the okay to begin a stretching regime has been granted (if it’s needed), the following stretches could be interspersed throughout a yoga practice. Reif also suggests trying them before and after doing any activity that causes elbow or forearm pain to see if they alleviate it.
1. Pull Your Hand Back
Stand in mountain pose. Lift your right arm (or the one involved in your tennis elbow, which is most often the right since many of us use that side much more), bring it out in front of you, and then flex your wrist to bring your palm toward you and your right fingers toward the floor.
Bring your left hand to the back of your right hand—just under your wrist—and gently pull your right palm toward you, applying enough pressure that you feel a gentle stretch. Hold here for three to five deep breaths, stretching your finger, wrist, and elbow extensors, especially the brachioradialis and extensor digitorum longus and brevis.
To feel a gentle stretch throughout the entire extensor side of the forearm, internally rotate the right shoulder to turn the pinky side of your wrist and forearm upward as much as you comfortably can. Hold here for three to five breaths.
2. Pull Your Fingers Back
From mountain pose, lift your right arm out in front of you again, fingers pointing down and palm facing you. This time, use your left hand to gently pull the fingers of your right hand toward you for a slightly different stretch of the finger, wrist, and elbow extensors. Hold here for three to five breaths. Then roll your right shoulder in and turn the pinky side of your wrist upward as much as you can without strain. Hold here for three to five breaths.
3. Getting a Tip
For an alternate way to access the same muscles and tendons, while you’re still in mountain pose, bring your arms straight down alongside you. Flex your right wrist so that your palm is facing up, curving your fingers up toward the ceiling. (Imagine you are a waiter receiving a tip on the sly.) Then roll your right shoulder inward and turn the pinky side of your hand outward, away from your body. Now lift your arm back behind you on a diagonal, and hold here for several breaths. Tip your head to the left to enhance the “neural glide” for the radial nerve.
Over time, by following the recommendations of your doctor or physical therapist, avoiding weight-bearing extension of the wrists and elbows, and doing stretches such as those described above, your pain will hopefully diminish. To prevent the repetition of this repetitive motion injury, stay aware of the demands you place on your wrist and elbow in and out of yoga practice.
Photography: Andrea Killam