In Part 2, we discussed some ideas for treating injured knees and backs, two common yoga injuries. We'll continue in this installment, first by examining wrist pain. We'll also discuss hamstring tears and shoulder injuries, two injuries that can lead to chronic problems.
Wrist problems tend to come on slowly, unlike many knee, back, and other yoga injuries. Your students may complain of a vague ache, and eventually sharper pain, as well as numbness and tingling in their hands, wrists, and/or forearms. The poses most likely to bring on symptoms include Adho Mukha Vrksasana (Handstand), Chaturanga Dandasana (Four-Limbed Staff Pose), and Urdhva Dhanurasana (Upward Bow Pose), all of which involve weight-bearing with the wrist cocked back. In this position, many students flatten the carpal tunnel, the bony canal in the wrist through which several tendons and the median nerve pass. Compression of the median nerve is the principal cause of carpal tunnel syndrome (CTS). Students with small wrists, women (who tend to have smaller wrists than men), and those who are overweight or have diabetes or thyroid disease are at greater risk for CTS.
If you watch a student with wrist pain do Adho Mukha Svanasana (Downward-Facing Dog Pose), you may notice that most of the weight in the hands is falling on the base of the palm near the wrists—in other words, right on the carpal tunnel. You want to teach them to place more weight on the knuckles and less on the base of the palm. This action is facilitated by engaging the muscles on the undersides of the forearms to lift the proximal wrist bones up toward the elbows. Students can practice this action on all fours, then see if they can maintain it when they push up to Down Dog.
For students who have a hard time learning this action, try placing a rolled-up mat or a slant board (thin edge toward the fingers) under the wrist as they do the pose. Once they've got the feel, see if they can reproduce it in the full pose. If, even with this correction, your students still have discomfort in Dog Pose, try having them work to bring the upper inner thighs up and back, which takes weight off the wrist. Bending the knees also lightens the burden on the wrist. If even that proves too much, try Half Dog Pose with the hands at the wall or on a counter top. Learning to place more weight on the knuckles and lift out of the wrist will help make all the other bent-wrist poses, such as Handstand, easier—though if the tendons in the wrist have gotten inflamed, it may be a while till your student is ready to tackle that pose again.
Hamstring tears in yoga typically occur near the sitting bone (ischial tuberosities) and often happen during forward bends such as Uttanasana (Standing Forward Bend) or Upavistha Konasona (Wide-Angle Seated Forward Bend). During rehab, you need to be careful with these poses, perhaps asking your students to practice them with the knees slightly bent or avoiding them entirely. The arms should never be used to crank the torso more deeply into the pose. Also be careful of standing poses that have an element of forward bending in them, such as Trikonasana (Triangle Pose) and Parsvottanasana (Intense Side Stretch Pose). Down Dog and Uttanasana may also be safer with slightly bent knees, which takes some of the pressure off the hamstrings while facilitating the stretch of the spine.
The biggest risk in rehabilitating hamstrings is doing too much too soon, leading to re-injury. Months of progress can be lost in seconds. Slower, more mindful practice is less risky than fast-paced vinyasa. Beyond resting the hamstrings to let the tissue repair itself, work on strengthening these muscles, as their relative weakness compared with the quadriceps may contribute to the vulnerability to tears. Backbends like supported Bridge Pose (Setu Bandha Sarvangasana), with the hips on a block, strengthen the hamstrings. In this pose, ask your students to visualize the sitting bone moving toward the backs of the knees, and the quadriceps lengthening.
Shoulder strains and injuries to the rotator cuff—the sleeve made up of the tendons of four muscles that help the shoulder form a socket around the head of the humerus bone—are nearly ubiquitous as people get older. They typically result not just from the precipitating event but from the cumulative effect of years of wear and tear. Since these injuries can make it difficult and painful to lift the hand over the head, you may need to avoid poses such as Adho Mukha Svanasana and Adho Mukha Vrksasana. In more severe cases, students may have difficulty even bringing their arms parallel to the floor as they prepare to move into standing poses. Some poses can be modified, however. For example, Virabhadrasana I (Warrior I) can be done with the hands on the hips rather than stretched overhead.
Shoulder problems, such as rotator cuff injuries and bursitis, often involve a significant degree of inflammation, so follow the recommendations on dealing with inflammation from Part 1[link] of this article. You may want to tell your students to avoid such poses as Chaturanga Dandasana entirely, and be very careful of those such as Gomukhasana (Cow Face Pose) and Reverse Namaste, in which many students poke the head of the humerus bone too far forward to be safe. Indeed, due to the weight bearing involved, Chaturanga may be one of the most dangerous poses for the shoulder if your student has this common postural habit. For these students, repeated cycles of Surya Namaskar (Sun Salutation) that include full Chaturanga, especially when they are done quickly (which makes correct alignment more difficult to achieve), cause many shoulder problems and may be contraindicated during their rehabilitation.
Like hamstring tears, rotator cuff injuries are easily reinjured, potentially setting your student back to square one. Though it can be hard for your students to do, being patient, never pushing through pain, and avoiding poses that could set them back are the best way to heal these stubborn injuries. It's OK to work through mild shoulder discomfort—and this may be necessary to increase range of motion—but any sharp pain, or an increase in pain after the practice, means your student has gone too far.
As with many injuries, nature and time may take care of the problem—if you can simply get your students to stop doing the action that hurt them in the first place and avoid contraindicated poses during their rehabilitation. They will also need a gentle asana program to build shoulder muscle strength, gradually restore range of motion, improve alignment, and foster relaxation.
In the concluding installment, Part 4, we'll explore the bigger issue of what injuries have to teach us and how they can be a vehicle into a deeper practice.