Working with Carrying Angles in the Elbows

by Baxter

Woman Carrying a Child Downstairs by Rembrandt

In addition to the tendonitis I wrote about last week Elbow Pain and Yoga, another fairly common situation that I have observed in my students over the years are elbows that appear to look like knock knees do at the knee joint. What I mean by that is that the elbow joint seems to bow inward instead of making a straight line from the upper arm bone to the forearm bones. In anatomical terms this is referred to as a “carrying angle,” and sometimes as hyperextension. This could be considered just a variation on normal anatomy of the arms at the elbow joint, but ever since I started studying yoga in the mid-90s, it has been implied by many of my teachers that a carrying angle in weight bearing yoga poses could present some problems for those practitioners. I’ll get to that in a few moments. 

Interestingly, if you or I stretch our arm out in front of us, fully extending or straightening at the elbow, with our palm turned up toward the ceiling (known as supination of the forearms), and we look at the angle between the humerus and the forearm bones, it is usually not a straight line. The forearm bones angle slightly out to the side, away from the midline. But, wait! If you turn your hand down toward the floor (known as pronation of the forearms bones), you will likely notice that the upper and lower bones of the arm now appear more aligned! This is true for many yoga practitioners, but not all. And when the arms are not bearing weight, such is in many of the standing yoga poses (Warrior 2, as an example), it is really a non-issue for someone with a carrying angle. However, when we look at the elbows in one of the most common modern yoga poses, Downward-Facing Dog pose (Adho Mukha Svanasana), practitioners with a carrying angle will demonstrate this bowed-inward appearance while doing the pose. It will also show up in other straight arm yoga poses where you are bearing weight on your hands, such as Upward-Facing Dog pose (Urdhva Mukha Svanasana, Side Plank pose (Vasithasana), Plank pose, and Handstand to name some of the more obvious poses. 

I should mention that hyperextension of the elbow joint, where, instead of 180 angle between upper and lower arms in full extension of elbow, the angle is greater than that, is often present in those with a carrying angle. In hyperextension, it is often loose or lax ligaments around the joint that allow for the greater angle, but it is also influenced by the joint capsule and the shape of the bones. In both the situation of the carrying angle and hyperextension of the elbow joints, there is potentially less stability and even contact between the ends of the bones at the joint. This could increase the chances for wear and tear between the bone surfaces, as well as strain on the ligaments and tendons, and the development of pain around the elbow joint. 

A HUGE however: Because there is great variety in our skeletal structure, influenced by muscles and connective tissue, allowing the elbow joint to “lock out” into full extension where the carrying angle or the hyperextension become evident may not mean that the yoga practitioner is destined to develop arthritis or tendonitis of the elbow joint. So, it may be that only yogis who have elbow pain in the setting of a pronounced carrying angle should modify their poses to try to eliminate pain around the elbow. 

If you are interested in reading a great discussion on this topic (and to avoid re-inventing the wheel), I’d recommend you check out this post from YinYoga.com’s Bernie Clark: 

Now let’s assume that you or your yoga student is experiencing elbow pain in the weight-bearing poses mentioned above. What modifications can you try to attempt to eliminate the pain and quiet down the underlying problem that might be behind it? Here are a few ideas: 

1. Take a break from those poses for a few weeks and notice if the pain subsides or goes away completely. 
2. Do modified versions of the weight-bearing poses, like Half Downward-Facing Dog pose at the Wall, or Side Plank pose (Vasithasana) at the Wall and notice if less pressure through the elbow joint results in a decrease or absence of pain. Stick with those variations for a while before re-introducing the full arm balances. 
3. In Downward-Facing Dog pose, try to slightly bend your elbows until your arm bones will line up evenly. You might need someone to tell you where that alignment is if you can’t see it yourself. Keep in mind that you will now be relying more on your muscles, so it is going to feel like a lot more work and you may not be able to maintain the pose for as long as you did when the elbow was fully extended. Build strength gradually! 
4. For poses where the arms are parallel, like Downward- and Upward-Facing Dog pose and Handstand, try placing a looped strap just below your elbow joint towards your wrists, on the thick parts of your forearms. Make the loop just big enough that when you press your forearms outward against the loop your arm bones line up at that 180 degree angle. The strap will take on some of the muscular work you had to do in #3, and you will probably be able to stay longer in the poses. This could allow you to better sense the even alignment of the bones and find it on your own without the strap over time. Notice if the pain is gone when using the strap.
5. Also in poses where the arms are parallel, try turning your elbow creases to face each other (they are probably turning away from each other). Once your elbow creases are facing each other, try rolling your upper arm bones slightly out (external rotation) at the same time you roll your lower arm bones slightly in (internal rotation). See if these actions bring your arms into a straighter alignment.
6. Working with your shoulder joints and hand placement can also re-align your elbow joints, so it would be worth exploring what more external rotation or internal rotation of the humerus bones does to your elbow joints. Turning your hands slightly in or out (abduction or adduction at the wrist joint) could also bring the bones at the elbow into a more even alignment. But you have to make sure you don’t trade pain in one joint for that in another! 

There may be other suggestions that some of our readers have tried for elbow pain attributed to carrying angles or hyperextension of the elbow. What have you found beneficial? And have any of you lived with this variation of anatomy without developing any problems? Let us know you experiences and thoughts on angles at the elbow!

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Elbow Pain and Yoga

by Baxter

As I was preparing for an upcoming workshop on Yoga for Elbows and Wrists, I decided to look back at our blog posts and see what we had shared with you over the last three years about elbows. To my surprise, there was not one dedicated post on the elbows (my sincere apologies to all the elbows out there!). It’s a bit surprising on both a professional and person level. Professionally, it is not uncommon for my students to complain about one of their elbows being sore or painful. And, personally, I have had intermittent bouts of elbow soreness over the years, most often associated with sudden increases in my violin playing. If I am at a music jam and playing for several hours (without enough regular practice time), I will often have right elbow soreness the next day that can persist for up to a week. Why the right one? It is my bowing arm and therefore the side that is repetitively flexing and extending at the elbow joint over and over as I play. On those occasions, I find myself modifying my yoga practice to address the soreness and limitations, both to keep the yoga from worsening my symptoms and to choose poses I think could speed my recovery.

The elbow joint is often referred to as a “hinge joint,” much like a door hinge that allows two movements, swinging open and closed, or, in the case of the elbow, flexing and extending. However, this is a bit simplistic, as just beyond the place where the upper arm bone, the humerus, and the lower arm bones, the ulna and the radius, meet to form the elbow joint is another important joint that adds a few more movements into the mix. This is the connection between the two forearm bones themselves. The top part of the radius and ulna abut one another in such a way that the forearm bones can roll over one another, which ultimately allow the palm of the hand to spin up and down, as in the action of giving and receiving some “skin.” To the untrained eye, this seems like “rotation” of the wrist joint, but in actuality, it starts at the elbow joint and has the fancy names of supination and pronation. And, like the knee joint, the elbow joint also has ligaments on the inner and outer aspect of the joint to keep the upper and lower arm bones from bowing in and out. Cartilage coats the bony ends of the elbow joint bones to keep them flowing smoothly over one another as we move the arm around.

Like many of the other joints of the body, the elbow is subject to wear-and-tear arthritis, problems that arise from injury, repetitive stress on the ligaments and tendons near the joint, and unusual skeletal variations. The most common source of elbow soreness and pain in my students by far is of the repetitive stress variety, so I’d like to focus on those for the rest of this blog. And, of the many possible causes of such repetitive stress, working at the computer is way at the top of the list. As a family doc, when my patients came in with elbow soreness and pain at the outer edge of the elbow, I’d diagnose them with “tennis elbow” and if the pain was on the inner elbow, it would be tagged as “golfer’s elbow,” even if they did not play tennis or golf! The underlying problem was really the repetitive action, whatever its source, leading to a chronic inflammation of the tendons in those areas that is called “tendonitis.” And this is probably what I was kicking up in my own elbows when playing my fiddle. The areas involved are often tender to touch and also painful when you flex or extend your elbow, or even when you flex and extend your wrist (which could be confusing, eh?).

Addressing Elbow Pain with Yoga

An initial approach to addressing this kind of elbow pain would be to avoid the repetitive movement that precipitates it, even if certain yoga poses might normally require such a movement. This means you have to be willing to improvise and change the appearance of poses as needed to keep the joint relatively quiet. 

Non-weight bearing poses for the arms are a good idea initially, so as to reduce the additional pressure and demands on the elbow joint that poses such as Downward-Facing Dog pose (Adho Mukha Svanasana) and Upward-Facing Down Dog (Urdva Mukha Svanasana) bring into the elbow. Choosing to focus on poses where your elbows are fully straight and extended, such as Warrior 1 and 2 (Virbradrasana 1 and 2), Triangle pose (Trikonasana) and Extended Side Angle pose (Uttitha Parsvokanasa), is a great starting place, and also has the added benefit of moving your shoulder joints through a pretty full range of motion, which could have positive effects on your elbows. 

Eventually exploring poses that bring your elbow joints into play with weight bearing on the joints should be done mindfully. You want to try and maintain the full movement of the elbow joint without worsening the pain. Start with Eagle pose arms (Garudasana), and if that feels OK, advance to Cow-Faced pose (Gomukasana) arms, which adds more deep bend to the joint. See Standing Shoulder Stretches. 

Eagle Pose Arms

Cow-Face Pose Arms

I also find that Wrist Flossing  can be beneficial for the elbows as well as the wrists, so take that for a test spin, too!

When your joints are beginning to improve, gradually add in more challenge for your elbow joints by taking a bit of weight onto them, such as in Half Downward-Facing Dog pose at the wall. 

If Half Downward-Facing Dog pose feels good, advance to full Downward-Facing Dog. When you start working on all fours, such as in Cat/Cow pose or Hunting Dog pose, play with the even press of your hands into the floor, evenly between the heels and balls of your hands and evenly between the pinky and thumb sides of your hands. This can often give you important feedback on how the placement of your hands relates to the even work of the elbow joints.

Use caution with the poses that super load the below joint, such as Pushup pose (Chaturanga Dandasana), and arm balances, such as Heron and Crow poses or Handstand. You might want to wait until your elbows are pain free for a while before learning these or adding them back into your practice. 

Finally, as I mentioned before, there are many other elbow issues that can cause pain and soreness. Some will benefit from the above recommendations as well, whereas others may need different approaches. I hope to share more about the elbows in the coming weeks, and if you have specific curiosities about elbows, please send me a comment!

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