Wrist pain from yoga: downward dog, plank and arm balances, where it hurts and what to change

Yoga is safe for most people, and wrist trouble is usually minorStrong evidence

Across 94 trials (8,430 people), yoga was about as safe as usual care and other exercise. Across 9 observational studies, most problems were mild and short-lived, and 1.9% were serious. In US emergency departments from 2001 to 2014, the arm and hand (the elbow, forearm, wrist, hand and fingers together) were 8.8% of an estimated 29,590 yoga injuries, and 94.6% of patients were sent home. In 1,702 German practitioners, injuries ran at about 0.6 per 1,000 hours of practice. The US National Center for Complementary and Integrative Health (NCCIH) calls yoga generally safe for healthy people when done properly with a qualified instructor, and in 9,151 women in their 60s, those who did yoga had no more joint problems than those who didn't.

Sources 1, 2, 3, 4, 5, 6

But new yoga pain is most often in the armsEmerging evidence

In 354 recreational practitioners at two US studios, 10.7% developed new pain caused by yoga over a year. The university's summary of the study says most of that new pain was in the shoulder, elbow, wrist and hand, possibly from downward dog and similar poses, and that 74% said yoga eased pain they already had. In the German survey, handstands, shoulder stands and headstands were linked with 29.4% of acute problems, and about a fifth of acute problems with a known site were in the arm (read from the paper's figure). Teachers and clinicians in a survey of 1,336 linked wrist injuries mainly with downward dog and plank variations such as chaturanga and side plank; that is opinion, from a low response rate.

In 321 adults who practise handstands at least weekly, across yoga and other disciplines, 56.7% reported recurring wrist pain, and 53.4% of those whose main discipline was yoga. Young gymnasts, who load bent-back wrists far harder than a yoga class does, often have wrist pain that carries on with unchanged training (another group). No survey has counted wrist problems in yoga on their own, so the share that is wrist pain is unknown. In our reading, wrist pain from yoga is a common nuisance in people who do a lot of weight-bearing poses, flowing classes, arm balances and handstands, and rarely a serious injury.

Sources 7, 8, 4, 9, 10, 11, 12

What yoga asks of the wristEmerging evidence

Most poses that put weight on the hands do it with the palm flat and the wrist bent back: all fours, cat-cow, downward dog, plank, chaturanga, upward dog, side plank, crow and handstand. In 20 adults on a force plate, poses on both hands put about half to all of their body weight through the hands at the peak, and a side plank about two-thirds through one hand. The researchers point out that the arms aren't designed to take weight the way the legs are.

In 10 trained practitioners filmed with motion capture, a sun salutation bent the wrist back to about 85 degrees in the eight-limb pose, near the end of the range most adults have, and it varied more between people than any other joint; the downward dog shape bent it back much less on average (about 31 degrees), again with very wide variation. In 8 wrists from donors, a flat-palm push-up raised pressure on the thumb side of the wrist joint compared with a knuckle push-up, and in 14 volunteers the force moved towards the back of the wrist and the little-finger side when the wrist was bent back. These are push-up studies; no study has measured wrist pressures in yoga poses.

Sources 13, 14, 15, 16

Telling the causes apartEmerging evidence

A general practitioner (GP) or physiotherapist presses on the exact spot, compares movement and grip with the other side, and asks what brings it on. The NHS sorts wrist pain by pattern: sudden sharp pain and swelling with a snap in an injury suggests a broken wrist; pain, swelling and bruising after an injury a sprain; long-lasting pain and swelling at the base of the thumb de Quervain's or arthritis; aching that's worse at night with tingling or numbness in the fingers, or a weak thumb, carpal tunnel syndrome; and a smooth lump on top of the wrist a ganglion.

Back-of-wrist pain that comes only with weight on a bent-back wrist and settles quickly is the load pattern. The same pain every time, for weeks, in one spot points to something more specific: in a hand surgery centre's patients with that pattern, a magnetic resonance imaging (MRI) scan found a problem in 84%, against 12% of a comparison group, most often a small hidden ganglion (76%), then a partial tear of a ligament between two wrist bones. One case report describes a yoga practitioner with bone forming in a strained wrist ligament.

Tingling is a nerve sign rather than a joint sign. In people with carpal tunnel syndrome, the pressure in the carpal tunnel was 32 mmHg (millimetres of mercury) with the wrist straight and 110 with it bent back 90 degrees, against 2.5 and 30 in people without it, and holding the wrist and fingers bent back for a minute, like prayer hands, raised it further. Rarely, a ganglion pressed on the ulnar nerve at the little-finger side of the wrist after downward dog, and one woman with an inherited tendency to nerve pressure palsies developed a dropped wrist after a month of trying crow pose; both are single case reports. A review of published yoga cases includes a torn tendon at the inner elbow after downward dog, and no wrist cases.

Sources 17, 18, 19, 20, 21, 22, 23, 24

When a scan or test mattersEmerging evidence

For load-related pain that is settling, no scan is needed (our reading of the NHS's first steps). An X-ray comes first after a fall onto the hand. Back-of-wrist pain that keeps coming back with loading, for more than a few weeks of changes, is where a hand specialist may ask for an MRI scan: the clinic authors suggest one when back-of-wrist pain comes with positions such as push-ups, yoga or Pilates poses. A finding isn't always the cause, since ganglions also show on the scans of many wrists that don't hurt. Carpal tunnel syndrome is usually diagnosed from the symptoms and an examination, with a nerve conduction test or a scan if the picture isn't clear.

Sources 17, 18, 25

How it usually goesEmerging evidence

No study has followed yoga practitioners with wrist pain, so this is our reading of the conditions themselves. Load-related pain usually responds to changing the position and building back up; the NHS says to see a GP if wrist pain hasn't improved after 2 weeks of looking after it at home. A ganglion often goes on its own, though that can take from several months up to a year, and carpal tunnel syndrome sometimes gets better by itself in a few months. Of acute yoga problems in the German survey, 76.9% recovered fully, 19.5% partly and 3.7% not at all.

Even after a broken wrist, most people get back to yoga: in 31 regular practitioners whose broken wrist was fixed with a plate, 90.3% returned, at an average of about 6 months for any yoga, 7 months for weight on the hands and 10 months for their usual practice. No one can promise a date.

Sources 17, 26, 25, 27, 4

Change the position first: push-up studies and coaching practiceEmerging evidence

No trial has tested a change to yoga for wrist pain, and no study has tested alignment cues, wedges, fists or forearm swaps in yoga. The swaps rest on push-up studies: the authors of one judged push-ups on a straight wrist likely safer, because the ligaments may take more load when the wrist is bent back, and in the cadaver study a knuckle push-up avoided the pressure rise of a flat palm. In handstand practitioners, grip devices such as parallettes or blocks, braces and warm-ups weren't linked with less pain; it is a survey of people who load their wrists hard, so it shows props aren't a cure, not that they don't help.

So, as our suggestion: take the bend out of the wrist (fists, push-up handles, or a wedge or folded mat under the heels of the hands), take the wrist out (dolphin, a forearm plank, sphinx, a forearm side plank), or take weight off it (bent knees in downward dog, knees down in plank and chaturanga, hands on a wall, a chair or blocks). Spreading the fingers and pressing through the knuckles and the base of the index finger is a common teaching cue that hasn't been tested; if the wrist still hurts, change the position rather than keep adjusting the hand.

Sources 16, 15, 9

Fewer vinyasas and a gentler class for a while: our readingEmerging evidence

A flowing class repeats plank, chaturanga and upward dog in every vinyasa, and the eight-limb pose of a sun salutation is where the wrist bent furthest back. In the German survey, people who mainly did power yoga reported the most injuries (1.50 per 1,000 hours, against 0.60 for all yoga), though that figure comes from 71 people with a wide margin of error. Skipping some vinyasas, lowering with knees, chest and chin, swapping upward dog for sphinx and choosing a slower class for a few weeks is our suggestion from these sources.

Sources 14, 4

Tell your teacher, and learn with oneEmerging evidence

The American Academy of Orthopaedic Surgeons (AAOS) advises discussing any illness or injury with your yoga instructor before class so they can suggest changes to the poses, and stopping or taking a break for pain. The Arthritis Foundation suggests arriving about 15 minutes early to speak to the instructor and ask about modifications. In the German survey, people who had only ever practised on their own, without a teacher, reported more acute problems (adjusted odds ratio 1.75).

Sources 28, 29, 4

Put weight back gradually, then build strengthEmerging evidence

The most concrete programme is an NHS trust's wrist leaflet, written for recovery after a broken wrist: lean a quarter, half, three-quarters and then all of your weight through a table for 5 to 10 seconds, then a wall, then the floor; then strengthen with a weight you can lift about 10 times before the wrist tires, up to 3 sets of 10, every other day. It works to an unpleasant stretch of about 5 out of 10 that settles within 30 minutes. The NHS also says to keep the hands and wrists moving with gentle exercises. No trial has tested wrist strengthening for wrist pain from yoga; the plan below borrows this programme and our wrist pain in push-ups and yoga guide.

Sources 30, 17

Carpal tunnel: yoga isn't off limits, on thin evidenceMixed evidence

In one small trial from 1998, 42 people with carpal tunnel syndrome did 11 upper-body poses and relaxation twice a week for 8 weeks or were offered a wrist splint; the authors concluded that yoga relieved some symptoms and signs better than splinting or no treatment, with grip and pain improving in the yoga group. A Cochrane review that includes it rates the evidence for all exercise and mobilisation in carpal tunnel syndrome as limited and very low quality. Because a bent-back wrist raises the pressure on the nerve, keep weight off the palms and hold prayer hands lightly while your fingers tingle. The NHS treatments are a wrist splint at night, then a steroid injection, and surgery if it persists.

Sources 31, 32, 20, 21, 25

Splints, medicines and the conditions behind itStrong evidence

For mild wrist pain, the NHS suggests resting the wrist when you can, an ice pack for up to 20 minutes every 2 to 3 hours, paracetamol or ibuprofen gel, cutting down what causes the pain and a splint, especially at night, while keeping the hand moving gently. Most ganglion cysts don't need treatment; a painful one can be drained, injected or removed. For carpal tunnel syndrome, a night splint comes first, for up to 6 weeks, and surgery usually cures it if other treatments don't work. Surgery is rarely needed for wrist pain from yoga; the diagnosis guides cover it.

Sources 17, 25, 26

Your yoga for now (written steps)

Our 3D figure shows the moves, not your hands, a wedge, blocks, fists or how many vinyasas a class does. These steps come from the AAOS, the Arthritis Foundation, an NHS trust's wrist leaflet, lab studies of push-ups and a national survey; where a step is our suggestion, it says so. None has been tested in a trial against wrist pain.

• 1. A fresh injury first: after a fall from crow, a handstand or another arm balance, with tenderness at the base of the thumb, swelling, a snap or numb fingers, stop and get it checked.
• 2. Tell your teacher before class what hurts and which poses you'll change, and ask for an option when the class moves on to arm balances, as the AAOS and the Arthritis Foundation suggest. For example: "My wrists hurt in downward dog and plank. I'll use my forearms or fists for a few weeks; could you suggest a change for the arm balances?" (our wording).
• 3. The hands: spread the fingers and press through the knuckles and the base of the index finger rather than sinking into the heel of the hand (a teaching cue, untested; our suggestion).
• 4. Take the bend out: a wedge, or a folded mat or towel under the heels of the hands, or fists or push-up handles in plank and on all fours (our suggestion, built on push-up studies).
• 5. Take the wrist out: dolphin for downward dog, a forearm plank for a high plank, sphinx for upward dog, and side plank on the forearm, especially with little-finger-side pain (our suggestion).
• 6. Take weight off: bend your knees in downward dog and push your hips back, knees down in plank and chaturanga, hands on a wall, a chair or blocks (our suggestion).
• 7. Fewer vinyasas: skip some and rest in child's pose, or lower with knees, chest and chin; choose a slower class for a few weeks (our suggestion; power yoga had the most injuries in one survey).
• 8. Arm balances and handstands last: they were the practices most often blamed for acute problems in one survey, and they come back one at a time in the last stage.
• 9. Hot rooms and sweaty hands make the hands slip and grip harder; a towel on the mat helps (our suggestion).
• 10. Getting back to a full class: add one weight-bearing pose or a round of vinyasas at a time, and keep the forearm and grip work going (our suggestion).

Sources 28, 29, 16, 15, 4, 30, 27

Tingling fingers and prayer hands

Holding the wrist and fingers bent back raises the pressure in the carpal tunnel. While your fingers tingle, keep weight off your palms, use the forearm swaps, and hold prayer hands lightly and briefly or with the palms apart. See a GP if tingling doesn't settle or your thumb feels weak, as the warning signs say.

Sources 20, 21, 25

A growing wrist, and after a broken wrist

A child or teenager who does handstands or arm balances and has a wrist that still hurts the next day should stop putting weight on the hands and get it checked; our gymnast's wrist guide explains why. After a broken wrist, put weight on the hand only when your fracture clinic says: the NHS trust leaflet starts it from about 6 weeks, and in one study regular practitioners took about 7 months on average to get back to weight on their hands.

Sources 12, 30, 27