Are your clients complaining of sore wrists?

Wrist pain is very common in Pilates.  From supporting the upper body in four Point Kneeling or Plank to Pulling Straps on the Reformer, all Instructors have had to modify or adjust exercises for clients with this common site of pain.

Often clients only discover wrist pain when they have over-extended themselves resulting in pain and or discomfort. Perhaps they avoid certain exercises or they mention that they can’t load bear anymore. So let’s discuss the most common causes and how we might support our clients in strengthening their wrists.

For non-pathological related pain, the two most common causes are

1.     Weakness

2.     Lack of flexibility

When we speak of weakness relating to wrist pain, we don’t just mean the strength in our wrist or forearm muscles.  The strength of all the muscles in the arm, shoulder, upper back and neck contribute to wrist pain and therefore strengthening these areas is paramount to avoiding wrist irritation and pain.

First up, lets break down what happens when we do a position such as four-point kneeling and or plank. Essentially we are looking to extend the wrist to 90 degrees, which is the maximum extension for most people who aren’t hypermobile.  It’s worth noting that full wrist extension isn’t a functional position. Just think about how often in daily activities you place your wrists in full extension. Therefore our soft tissues in the wrist and forearm are unaccustomed to this amount of extension.   Once you add any of the following to the wrists:

-        load of the upper body

-        weight resistance

-        reduction of contact points with the floor (reducing the base of support)

-        added load with inflexibility

the result may lead to the joints of the wrist bearing all the weight and resulting in pain.

So what can Pilates instructors and clients do to reduce the pain?

Alignment – the same way optimal leg alignment can reduce knee pain, optimal alignment of the shoulder, elbow and wrist will distribute the load and increase strength in the muscles which maintain this alignment.  Start with the shoulders, then ensure the elbows aren’t hyper-extending, and finally at the wrist and hand, stack the wrists under the shoulders, spread out through the fingers, distributing the load from the heel of the hand all the way to the fingers.
The broad relationship between the fifth finger and the thumb is also quite important. By broadening the distance between the fifth finger and the thumb it increases tension.  This increased tension restricts torsion load, and increases axial load. 

Stretching – Due to the increased time spent on computers the average adult doesn’t move through wrist flexion and extension regularly enough.  Adding wrist and forearm stretches to daily routines will greatly improve the wrist joint's flexibility, function and longevity.

Flexibility – try these exercises or movements to improve flexibility:

-        Rotations in both directions

-        Prayer stretch or slides

-        Assisted flexion and extension

 

Engage the core – we all know it, we all say it often enough! In all exercises we teach in Pilates, we need to ensure our clients are engaging the core when performing exercises that load the wrists. By engaging our core, the load is distributed across many muscles and joints, think of a marquee with only two poles and stabilising ropes, versus a marquee with many poles and ropes.

So let’s look deeper into the anatomy

The wrist, forearm, upper arm and shoulder have many intricate bones, muscles, nerves and blood supply.  There are eight small bones in the wrist and nineteen in the hand, allowing for multiple movements and stability through the ranges of movement.  Due to the complexity of the entire limb, causes of wrist pain can be challenging for medical professionals to diagnose.  The most commonly listed cause is repetitive motion.

Anatomical description from the National Library of Medicine (US) -

The forearm is the section of the upper limb from the elbow to the wrist, whose bony structure is formed by the radius (laterally) and ulna (medially).  Two muscular compartments - an anterior (flexor) and posterior (extensor) compartment - contain together twenty muscles that act on the elbow and wrist joints, as well as carpometacarpal, metacarpophalangeal, and interphalangeal joints of the handThus, the forearm muscles are essential to the fine motor actions of the upper limb, allowing for complex movements of the arm, wrist, and fingers.

Brittney Mitchell; Lacey Whited.

Cues for improving muscle recruitment

1.     Connect from your armpit all the way down to the heel of your hand (or palm if holding straps)

2.     Imagine the entire arm as one lever moving or stabilising from the shoulder joint

3.     Push the floor or footbar or reformer frame away through the entire exercise (closed chain exercises)

4.     Spread through the entire hand.  For example don’t allow the palm of the hand to arch away from any surface

5.     Engage the fifth finger (turn on your pinky) as this will engage the serratus anterior and the latissimus dorsi

Suitable modifications or adjustments and props

Many clients find relief from decreasing the amount of wrist flexion as this results in raising the heel of the hand higher than the fingers.

On the mat – roll the end of the mat and position the heel of the hands on the rolled section of mat, or position the client on their elbows rather than hands by using a yoga block or Pilates Reformer box.  Remember shorter levers reduce the force needed to move or sustain weight. 

On the studio equipment – similar to the mat, raise the heel of the hand, use a box under the elbows.

Props like a rolled-up towel or foam roller can also assist when adjusting an exercise. While props like the spikey balls, Markarlu, etc will aid to increase blood flow, stimulate nerves, increase range of motion and flexibility and relieve tension.

 

Let’s look a little closer at a couple of common Pilates exercises and how to adjust them to suit.

1.     Plank to Pike on the Reformer – this exercise can be done multiple ways.  You can face the footbar and place hands on the frame or the footbar.  In this option, clients can adjust the exercise to position their elbows on the frame or footbar but this may be somewhat uncomfortable and unsafe.  Additionally, when facing this direction the resistance is to lower abdominals and leg muscles.  If you position your clients the other way and use the short box under their elbows then the exercise becomes safer, less painful, AND the added bonus is that the resistance is applied to the arm and shoulder muscles which assuming optimal alignment is present, will work towards decreasing wrist pain in the long term.

2.     Balance Control on Reformer – Place the hands on the shoulder rests in the less that 90 degrees of flexion position discussed earlier to reduce the stress through the wrist joint.

Side Bend on the Mat – Perform the exercise on the forearm to reduce the load on the wrist whilst still working on shoulder strength and stability.

 

So for clients who refuse to work on their wrists, what can you do?

If your client is resistant to strengthening their wrists due to pain or advice they may have received from a medical professional this is actually great!  Why, because the wrist is unlikely the cause, just the site of pain.  Therefore work on the client's shoulders, posture, core, etc.  It can help to cue your client to focus on the movement of the humerus and just allow the rest of the arm to follow.  (assuming optimal alignment is present).

Building or rebuilding confidence post-pain or when pain is still present is of utmost importance.  Explaining to your client that the pain won’t disappear but that we are striving to work with an around the pain.  This may look like short stints of time in a four-point kneeling position, then interspersing with leg or core exercises before returning to arm exercises like long box arms on the reformer or seated lat pull-downs on the Cadillac.

Considering the importance of the wrists in the body and how often this joint is utilised in daily activities, wrist flexibility and strength should be a focus of each session.  And this isn’t difficult as any arm exercise if completed effectively, will benefit the wrist.  Exercises where the load or resistance is applied to the elbow or upper arm will benefit the wrists.

In short, we all need to work our wrists more, whether it's our clients or our own. It’s important that we understand the benefits of this work and find ways to incorporate more of it into our teaching. 

Tracey Nicholson is the Director of Tensegrity Training an RTO that offers several different levels of training to help you at any stage of your career in Pilates. Offering accredited training, short courses and somatic and movement therapy, Tracey and her team are dedicated to their clients and comprehensive in approach. You can find out more at tensegritytraining.com.au

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