It’s not uncommon to have wrist pain while in a weightbearing position during exercises like push ups and handstands.
Here’s some reasons why, and what to do about it.
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#AskMikeReinold Episode 290: Wrist Pain While Weight Bearing
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Show Notes
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Transcript
Student:
All right. I’ve got this one. So we have James from Salt Lake City. What strategies do you use to treat pain with wrist extension in weight bearing positions? This seems to be a common issue with athletes of all levels. Despite spending lots of time memorizing intricate details about the hand in school, I feel like I have a poor grasp on how to treat issues like this.
Mike:
Awesome. That’s a great question, James. I actually appreciate that too, because I appreciate what you added there at the end, right? We study so much about the hand, but then you have pain with weight bearing and you’re like, “Well, the hand’s not even a weight bearing joint.” So this doesn’t really add up anatomically for what I was expecting. But this is definitely something I think we’re seeing more and more as people get more into fitness and we have the fitness athletes out there that are doing lots of things like that. I don’t know. I hate to call on somebody, but I feel like this is such a Dave Tilley moment, right here, just with the gymnastics. Right? You have lots of weight bearing and impact type things with the wrist, but why don’t we start off with that? And obviously Dave, the gymnast is one thing, but also just like our typical type of patients, why don’t we talk a little bit about maybe why that might happen and then some things that you tend to do. What’s up Dave?
Dave:
Yeah. So I think like you said, the whole arm is not really built for weight bearing, right? You don’t have the evolutionary mileage that you have from your hips and meniscus and cartilage in your knees to support that. The ankle is analogous to the wrist and you don’t have this large calodome that could protect the wrist. So it’s definitely not built for that. And also if you look at the research on where the force goes, it’s definitely not equally distributed, at 85 to 93% of the weightbearing forces go on the radio side through the scaphoid. So you have a very large… Possibly depending on what you’re doing, pushups or, whatever all the way up to, if you are a gymnast doing handstands and stuff, but you have a lot of body weight going on a very focal, small surface area within the weightbearing portion of scaphoid.
Dave:
So it’s pretty easy to have issues pop up there. Similar to cartilage in the knee when you have a really large amount of force through a small surface area, so that’s a risk factor. And then also too is, I think a lot of people are doing grip work that are in the general fitness industry, right? So there’re barbells, kettlebells, dumbbells, whatever. In the same way that someone who has very stiff gaffs may limit dorsiflexion of the ankle and change the kinematics of the joint, limited flexor-pronator mass and fish flexor-pronator for soft tissue can definitely limit the extension of the wrist, which can obviously put more pressure on the joint. So that’s a background. I think that most people also don’t do a ton of risk conditioning before they get into weightbearing stuff. They just do pushups.
Dave:
Some of our friends, who are a very high level gymnasts, do a crazy amount of wrist prehab and rehab, the same way that a baseball player might do for their elbow and their forearms. So it’s typically not something they work on, but in terms of dealing with it, I think the first step is screening out mobility, which isn’t often thought about. So the same way you can do a weight bearing dorsiflexion test, there’s no literature on this, but you can do a weightbearing close chain, wrist extension test. That’s what we use for most of the athletes that we work with. So you have someone go quadruped and you just essentially put them on the corner of a box or a table and you see if they can get their shoulder to translate all the way over their wrist. You’d probably want to see about 100, 110 degrees because that’s what most people need to fully do weight bearing with pushups or stuff.
Dave:
So you’d probably want to screen that first and then figure out if someone has a mobility limitation. And the two things that would be with that are, like I said, forearm soft tissue, so getting a lot of soft tissue work with flexor pronator soft tissues and doing a lot of stretching for that, is pretty good. And then the joint itself can be limited as well. If somebody has a cranky or irritable joint, the same way you could have an anterior talo joint irritation. You could have problems there too. So the same joint glides you would do on the ankle, we would just do joint glides on the wrist as well, and try to have somebody do that in a close chain position. And then from there, after you look locally, you zoom out globally and see does someone have limited overhead elevation if they are doing things that required overhead.
Dave:
Sometimes there’s people pressing barbells with their wrist back, it’s not “weight bearing”, but it still bugs me the same way that doing pushups might. So clearing up any overhead mobility limitations or T-spine mobility stuff is good. Getting really strong upper back and scap, try to support some of the forces overhead. If someone does have an issue, that’s not able to be solved with some of those things, you do want to modify a little bit, so maybe change their grip position to ear to neutral and pushups, or they do make braces that gymnasts use to prevent that end range extension, if someone just doesn’t have great risk flexibility. So I would say just work your way through what can change, what’s modifiable versus what’s not. And then just see if there’s a way you can still get them to their goals without too much pressure.
Lenny:
All right.
Mike:
Yeah. I just wanted to pause just to let that all sink in, because that was an impressive answer. Did you prepare for this or something? That was a dissertation.
Dave:
I just see 477 gymnasts per month with [crosstalk 00:06:30]
Mike:
That’s very interesting. That was a very Lenny ask type response right there too.
Dave:
That was my Lenny rant.
Mike:
Complete dissertation on a topic in five minutes without pausing to breathe. That was impressive, Dave. So I’ve got a question and anybody jump in on this one too. So I think obviously everything Dave just said was amazing. What about instability, which I don’t think you really touched on as much, but what about somebody that has a loose wrist, because I think I see that quite a bit. They have a loose wrist, then they start doing a bunch of stuff. Is that a thing? Do people see that? Anybody else want to jump in on that?
Dan:
I think it goes back to that whole point we were talking about before, is that the wrist wasn’t really designed for what we want to throw at it. You see this in the weightlifting world as well. So if you think about a snatch, when you snatch and catch a barbell, especially if you’re lifting a lot of weight, you’re at end ranges, right? End range extension, even the same thing in a bench press. Talk to Dewey about his wrist and how his wrist feels when he benchpresses. He’s got a lot of mobility all over his body, especially in his wrist. And I think when you have an unstable joint and you’re asking it to bear a lot of load and it wasn’t designed to do that, it’s even more challenging for the wrist joint. Right? So I think for those folks, you’re probably going to have to do even more strengthening.
Dan:
Just to build on what Dave said earlier, because I see this a lot because I don’t work with gymnasts. So gymnasts classically do a ton of conditioning for the wrists and they still have trouble. My guys are… let’s say you’re 40 years old and you decide to do a handstand for the first time in your life, and you’ve never loaded your wrist and it starts to hurt and they’re like, “Why does my wrist hurt?” And you’re like, “Well, we haven’t done any conditioning.” So part of it is that we a, have to get you out of pain, but then you have this monumental task of building up the wrist strength and stability to support your full body weight. And you’re working against your anatomy and what the wrist was designed to do. So I think to go back on your point, someone who’s hyper mobile is probably going to have an even tougher time.
Mike:
Right. And again, just like some of the other joints that we talk about when you’re looking for high level of stress at end range of mobility in a joint that probably has some laxity, those add up sometimes to a bit of a poor recipe. And I don’t think we often look at the wrist joint like that. We talk about high velocity and high forces at end range of motion for things like the shoulder, for example. But for some reason we don’t say that when you’re doing a pushup or a handstand, that’s at extreme end range of motion of wrist extension for you, that’s a unique position that you may not be ready for. So, Mike, what do you think?
Mike Scaduto:
Well, I was just going to touch more on the modifications of certain exercises that you can do. Dave touched on moving to a more neutral grip wrist position for a pushup. So a couple ways that I will do that is have people do pushups holding dumbbells. So the dumbbells resting on the floor and their hand is in a more neutral position. That can obviously eliminate that end range extension position. If you wanted to be more specific to a traditional pushup, you could throw a little bit of a wedge or a rubber pad under the heel of their hand, that would put them into a little bit more reflection to start. And then I would limit that wrist extension at the bottom of the pushup. In terms of the bench press, you could try different types of thickness of bar, if you have access to that. Maybe a thicker bar would help to limit some stress on the wrist.
Mike Scaduto:
Maybe put a little more stress on the muscle around the wrist, but sometimes the thinner bar in my experience can cause more wrist extension in the bench press, so that would be a couple ways you could modify existing exercises to decrease stress. And then you probably want to look at your overall volume of loading through the wrist as we discussed. When you start adding all those things together, probably more stress than you realize, so you probably want to cut back on some of the volume of certain exercises that put more stress on the wrist.
Mike:
Yeah, that’s great, Mike. And think about it too. Oftentimes let’s say you’re doing a pushup, you’re doing that for a push base strength. You don’t want the wrist to be your limiting factor for your ability to actually get some benefit from that exercise. So I think that’s fantastic. Diwesh, if somebody comes to you in the gym and they have this pain with wrist extension, anything else that you would do? Is there anything you’d do coaching wise or are there cues or is there improper technique with some of the things sometimes? What do you think?
Diwesh:
Yeah, I think Mike definitely covered a lot of the modifications that I was going to mention. I think using a fat bar is a really good way to take someone who wants to continue bench pressing and building some pushing strength, and put them in a position where their wrist is good enough to press and get the benefits of a good pressing exercise. And then obviously the modifications to the pushups. The things as far as other modifications, technique wise and stuff like that I tend to look at, or maybe even just like, are you prepared to do an exercise like this, is going to go back to the idea of screening for mobility. So an example that we see quite a bit is, let’s say we have a college athlete that has to do cleans and their strength conditioning program at school.
Diwesh:
So we got to try to get them to do cleans in their summer off-season training program. Well, are you able to catch a safe clean in front rack? If you’re not maybe we take the first month to really build up that mobility, build up a little bit of tolerance to get back into that risk extension position, and then try to work our way back into that catching a clean position. And then maybe in the meantime, we get to work on some front squats with a wrist strap holding you up here like this. So those are the things that I tend to go to. But I think Mike did a good job of covering a lot of the modifications as far as different tools that we can use to put people in positions where they can still train the rest of their body without having something as simple as a wrist limitation prevent you from doing [inaudible 00:12:22] get too big and strong.
Mike:
Yeah. That’s a good point. I bet you a lot of people jump right into things like cleans, for example, just because that’s in their program this month, but maybe they haven’t been screened to see if they have the mobility for that. I wonder if that’s to aggravate it.
Diwesh:
For sure.
Mike:
So, one last question I have, because I just think it’ll really help pieces together. I want to go back to Dan for this one a little bit here, but you talked about a lot of people just jump in without having the capacity to potentially do that. Can you just touch on that real quick on if you had somebody that wants to get into things like handstand pushups or something and they don’t have the capacity, what are just a couple ways that you help them build up that workload to be able to tolerate that stress?
Dan:
I think it really depends on you got to meet the person where they are. I actually think just regular strength training is a great way to build up the strength of your wrist. It’s funny, we don’t think about the wrist from a training perspective, or the wrist or the hand, really. You don’t have bodybuilders doing hand day. You know what I mean, there’s no wrist day of the week, but really we put stress on it just like anything else. I think a really good way to build up some strength capacity, of the wrist is to just do basic barbell and dumbbell pressing exercises because generally speaking, you’re going to have the wrist in a little bit of extension while you’re pressing. So that’s a good, basic starting place. From there you can start doing some weight bearing and usually that’s in a pushup position, maybe that’s an elevated pushup to start.
Dan:
From there, I like to work to different crawl variations. And then from there you can do more challenging overhead stuff like wall walks, I think is a really good one that doesn’t put you at full end range, wrist extension, but it’s very challenging on the wrist. And then you can work up over the course of time. I actually have a bunch of weird rehab exercises, I’ll probably make an Instagram post over the course of time, that helps us strengthen the wrist. But your basic wrist strengthening is often ignored. So resisted wrist flection, wrist extension. I also like a lot of arm work because it makes your arms look really good, but also is going to strengthen the wrist and we tend not to think about that too much with our arm exercises. That’s one of my first go-to movements for people that have elbow and wrist problems over the course of time. So throwing in some accessory exercises while we slowly ramp up some of the stress on the wrist and extended position.
Mike:
That’s awesome. Yeah. Perfect. Awesome. So James, going back to your question, do you see how we really didn’t talk about any of the intricate details of the hand that much either? That wasn’t the main points that we got across with these things. I think there’s a lot of different ways that you can probably help people build their capacity to handle those workloads and then probably modify some things to help them with it. So hopefully that helped. If you have a question like that, head to the website, mikereinold.com, click on that podcast link and you can fill in a form. And please head to iTunes. Is this the iTunes head to Apple Podcast and Spotify to subscribe. Rate and review. And we’ll see you on the next episode.
