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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Hyperextension of the Knees and Yoga

by Nina

Hyperextending!

Typically it’s not me who writes about anatomical aspects of the asana practice. After all, we’ve got both Baxter, an MD who teaches anatomy to yoga teachers and Shari, a physical therapist who teaches anatomy to yoga teachers, on our staff. But after reading Baxter’s post about the standing leg and knee in Warrior 3 pose (Vrbradrasana 3), I decided to write about hyperextension in the knee joints in general because, you see, I have it myself. And I have been working with it in one way or another for about fifteen years (after it was pointed out to me by a couple of my teachers). I decided that since I had a lot of knowledge about it, it would be good to get it down in writing. 

As Baxter said in his post, hyperextension of the knee joint means that your knee joint has a slightly greater range of motion in extension than the average person’s does. In other words, in people with hyperextension of the knees, when the knee is straight, instead of the femur bone on top and the shinbones on bottom forming one straight line, your knee joint bows slightly backwards. I’d like to add to what Baxter said by observing that when your knees are hyperextended, your kneecaps don’t face straightforward; instead, they turn in slightly, with the inner edges pressing back more than the outer edges (making you look a bit knock kneed). Also, with hyperextended knees, you tend to bear more weight on your heels than on the balls of your feet and your thighs press back so they are not aligned directly over your shins. All this unevenness in your legs, knees and feet is the reason there is concern about hyperextension, with concern that it could lead to uneven wear and tear on the cushioning cartilage of your knee joint, which could result in dysfunction and pain down the road. 

Rather than simply avoiding poses where you tend to hyperextend your knees, I believe that by observing the unevenness in your legs, knees and feet, and making adjustments, you can bring your legs, knees and feet into a healthier alignment. And in this post, I’m going to share with you how I do that myself.

First I’ll recommend that you test yourself to see if you have hyperextension rather than knock knees, and then I’ll describe a few techniques for correcting your alignment, both as you move into and out of poses and while you are practicing them.

Testing Yourself

1. Start by standing in front of a mirror in Mountain pose (Tadasana), with your feet together (yes, together). Now look at your knees. Are they turning slightly in toward each other and coming closer together than the rest of your legs? This could be either a result of hyperextension or knock knees.

2. Next, bend both knees by moving your shins forward and shift some of your weight from your heels to the balls of your feet. Then straighten your knees by lifting from your thighs, while keeping some of your weight in the balls of your feet.

3. Look at your knees again. Are they now facing straightforward with more space between them? If so, you have corrected your hyperextended knees. If there is no change, you may have knock knees. But try the adjustment once more just in case.

Moving into Straight Leg Poses

The technique you just used to correct your hyperextended knees in Mountain pose test is one that you can use as you move into any straight-legged standing pose. For example, if you are moving into Warrior 3 (Vrbradrasana 3) or Half Moon Pose (Arda Chandrasana), where you bend your knee first and then straighten it, you will bend your knee by moving your shin forward and shifting some weight onto the ball of your foot. Then, as you straighten your leg to come in the pose, you would lift from your thigh to straighten your knee as you keep some weight in the ball of your foot. (As you come out of the pose, use the same techniques to bend and then straighten your knee.)

Warrior 3

For poses such as Triangle pose (Trikonasana) and Pyramid pose (Parsvottanasana) where you normally move into the pose with a straight leg, you can try changing the way you move into the pose, as it is the front knee in these poses that you tend to hyperextend. Using Triangle as an example, you would take the foot position for the pose and raise your arms out the sides. Then, bend your knee by moving your shin and shift some weight onto the ball of your foot. Next, as you come into Triangle pose, lift from your thigh to straighten your knee as you keep some weight in the ball of your foot. Does it feel different to you?

Triangle Pose

Working in Straight Leg Poses

When you’re already in a pose, you can make adjustments to bring your legs into healthier alignment. 

First, in any pose with a straight leg, even balancing poses such as Tree pose (Vrksasana), you can slightly bend your knee and then straighten it again using the technique I described above. One week I tested this technique with every single standing pose in Light on Yoga, and found benefits in almost every single pose. In many poses, such as Dancer’s pose (Natarjasana), this adjustment brought me deeper into the pose!

Second, without bending your knee, you can try softening your front thigh muscles (quadriceps) and allow your thighbone (femur) to move slightly forward so it aligned more directly over your shinbone and more weight moves onto the ball of your foot. This will bring your leg into a straighter alignment. I just learn this one recently, and it works well in Half Moon pose (Arda Chandrasana).

Working in Seated Poses

In seated poses with one or more straight legs, including forward bends and twists, people with hyperextension of the knees tend to press the knee of their straight leg down toward the floor when their foot is fully flexed (vertical), hyperextending the knee. So, instead of flexing your foot in these poses, try pushing the ball of your foot a bit past your heel (without pointing your toes). I call this the “Barbie foot,” as it looks like the doll’s feet without her high heels on, and I’ve noticed Iyengar uses this foot position. The result is that your knee no longer hyperextends and—additional bonus!—your hamstrings soften a bit because pressing your front foot forward loosens the tug on the calf muscle, which then loosens the tug on the hamstrings, allowing you to come more deeply into forward bends. 

Moving into Bent Leg Poses

Remember that people who hyperextend tend to have knees that turn in slightly. So in weight-bearing poses with bent knees such as Warrior 1 and 2 (Vrbradrasana 1 and 2) or Extended Side Angle pose (Utthita Parsvakonasana), it’s a good idea to try to ensure that you’re bearing the weight evenly on your bent knee. Use the same technique of entering the pose by bending from your shin and moving some weight onto the ball of your foot. And, as you bend, pay attention to your inner back knee, deepening it as much as your outer back knee. This will help align your kneecap directly over your second and third toes and distribute your weight more evenly.

Extend Side Angle Pose

As you come out of the pose, use the same technique to straighten your leg as I described above, lifting from your thigh while keeping some weight on the ball of your foot. 

Thanks, Donald!

Whew! That’s it for now. I’d like to end by saying that I learned almost all of this from my teacher Donald Moyer, both while I was training with him to become a yoga teacher and in his ongoing classes. I'm very grateful for all that and more....

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The Standing Leg and Knee in Warrior 3 Pose

by Baxter

A funny thing happened a few weeks back as I watched my teacher trainees teaching one another: I saw things happening in their bodies that I miss when I am  the one teaching. That is the benefit of sometimes just watching what’s happening around you! And the most interesting thing I noticed was what happened to the standing leg and knee when one of them was teaching Warrior 3 to the others. I am fond of Warrior 3, and often also frustrated by it, too. It requires balance, strength and flexibility in different parts of your body. Your standing leg hamstring has to be flexible enough to straighten at the knee while your pelvis, top leg and torso all tip over it. Your back body muscles have to be strong enough to keep your top leg, torso and sometimes arms all in one long line parallel with the floor resisting the pull of gravity. Your shoulders have to be flexible enough to take the arms overhead for the full expression of the pose. And those are just the most obvious things going on!

What I saw that day relates to the alignment of the standing leg knee joint and is most relevant to you practitioners out there who know you are prone to hyperextension of the knee joint. Hyperextension of the knee joint means that your knee joint has a slightly greater range of motion in extension than the average person does. In other words, in people with hyperextension of the knees, when the knee is straight, instead of the femur bone on top and the shinbones on bottom forming one straight line, your knee joint bows slightly backwards.

Nina Hyperextending Her Knees

There is some controversy as to whether this is a problem in the long run. On the one hand, it likely allows those of you out there with this kind of knee joint the ability to do many of the more challenging yoga poses where the legs are straight. God knows I could use a bit of that openness in Standing Forward Bend (Uttanasana)! But there is some concern that it could lead to uneven strain on the supporting structures of the knee and could also lead to uneven wear and tear on the cushioning cartilage of your knee joint, both of which could result in dysfunction and pain down the road. So, it may be worthwhile to minimize hyperextension in the knees when possible!

What I noticed that fortunate day was the following: When the students did the Warrior 3 variation in which the legs and torso are parallel with the floor and the arms are out to the sides of the body at a 45 degree angle, the standing leg was very vertical and I did not observe much hyperextension in the 8 or 9 students who normally exhibit this tendency in some of their standing poses.

But the moment they shifted to the “full” pose, where the arms are brought forward along side the ears, am amazing thing happened: everyone’s center of gravity shifted a bit forward in the body, and the body appeared to slide back a few inches in space.

And in that moment, all my hyperextenders hyperextended in that bottom knee in unison!!! It was silent, but visually exploded into my awareness! I was stunned, but it was confirmed when they did the pose on the second side. What’s a newly enlightened (at least in this case of Warrior 3) teacher to do? Share the news with you all, of course. I have been teaching the pose in the last two weeks, and I am continuing to see this pattern of vulnerability in the knees of my students who have extra flexibility. 

You may be asking yourself what to do with this new information? If you are a stiff practitioner like me, you won’t need to do anything with it personally, unless you teach. Then I’d suggest you confirm this observation for yourself in some of your students. But if you have flexible knees yourself, you might observe your Warrior 3 from a side view in a mirror or have a trusted friend or teacher watch you in each Warrior 3 variation and see what happens in your knees.

If you do note a significant increase in hyperextension in the full pose, you might skip it (doing only the version with arms out to the side) or do it less frequently. Alternatively, check with your yoga teacher to see if he or she has techniques that you can use the bring your standing leg in full Warrior 3 into a healthier alignment. If so, try using those techniques to adjust the alignment of your standing leg in Warrior 3 both in class and when you practice at home. After all, this is a modern yoga pose, and in my book that means you can modify and adapt it to suit your unique needs. I hope this information is useful in the ever-changing exploration of your yoga practice.

Cautions: If you have low back pain, you may have to drop your lifted leg a bit lower or bend your back knee to reduce the weight stress this pose puts on your lower back (even a micro-bend to the lifted leg can be helpful). If you have arthritis of the neck, you may want to avoid lifting your head to face forward. As always, use common sense. It if hurts to do the pose, come out and ask your teacher for some feedback about what you’ve been doing. If balancing is a big problem and you’re just getting frustrated, return to the wall version.

If you’re having a lot of trouble and want to work your way gradually into the pose, you can do the pose at an angle instead of parallel. For more tips, see Nina’s post Taking on a Yoga Challenge. For additional instructions, read our entire post on Warrior 3 Variations.

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