Asana Analysis: Tree Pose/Vrkasana

Tree pose is a great standing balance pose because it is so versatile. It can be adapted to provide a challenge to a wide spectrum of abilities. It’s simplicity allows for mastery of the subtler aspects of asana.

Muscles Stretched: Adductors, including pectineus of the lifted leg.

Muscles Strengthened: Gluteus medius, tensor fascia latae, quadriceps, gastrocnemius, anterior and posterior tibialis, peroneals and intrinsic foot muscles of the standing leg; hamstrings, iliopsoas, piriformis and other external rotators of the lifted leg; transverse abdominus, pelvic floor, and spinal extensors

Points of Body Awareness:
*Before lifting one leg, be sure to really ‘root’ through the standing leg. In other words, make sure the foot is in neutral posture (inner arch slightly lifted, outer heel in alignment with the pinky toe, toes actively spreading), the quadriceps are engaged and lifting the knee cap up, the knee is strait but not hyperextended, and the hip muscles are engaged, gently drawing the ball of the hip into it's socket.
*Once the lifted leg is in place, note the alignment of the hip and pelvis. Is the outer pelvic bone of the standing leg hiked up? Is it jutting out to the side? If so, level the pelvis and center the hip by finding more action in the muscles on the side of the hip (gluteus medius and TFL).
* Draw the navel in toward the spine to engage the deep abdominal muscles (the transversus abdominus) and lift up through the perineum to engage the muscles of the pelvic floor.
*Feel two lines of energy moving in opposite directions. From the navel, feel energy move down through the standing leg and spread out into the ground, like the roots of a tree. Also feel a line of energy that moves upward from the navel, providing space between each vertabrae and lifting and lengthening though the crown of the head.
*The arms can be in any number of positions. You can keep them in ‘prayer position,’ with palms together in front of your heart. You can stretch them out horizontally to aid in balance or you can reach overhead, either bringing the palms together or keeping the hands shoulder-distance apart.
*Maintain a steady gaze. Keep the neck and jaw relaxed. Do 5 to 10 TATD breath cycles.

To Modify: For those who have tightness or decreased range of motion in the hip or knee, do not force the lifted foot all the way up to the groin. Instead place the sole of the foot on the inner calf, just below the knee. This will give you more freedom of motion in the hips and lower back, allowing for better alignment. It will also decrease the risk of injuries.

For those who have a lot of difficulty balancing on one foot, there are a couple of options. You can unweight one foot but keep the big toe on the ground. Lift the heel and turn the knee out. As you get more steady with 90% of the weight on your strait leg, try lifting the big toe off the floor for just a few seconds, gradually lengthening the time as your strength and balance improve.


Another option is to do Tree pose with one foot just below the opposite knee and with the fingertips on a wall in front of you. Start with all 10 fingers. Eventually progress to balancing with just one or two fingertips for support.

To Challenge: I encourage all people to try the modified version of Tree Pose with the sole of the lifted foot just below the standing knee, on the inner calf. I find that propping the foot on the groin of the standing leg is just that... propping. Although it may feel good, the traditional version of Vrkasana is more passive. Once you’ve got that leg in position, there is not a lot of work to be done to hold it in place. This is fine and can offer benefits from the pressure point on the inner thigh however if you want to work on improving strength and endurance of the pelvic girdle, keep the lifted foot below the knee. For an added challenge, try moving the lifted foot slightly away from the standing leg. This requires co-contraction of the muscles all around the hip.

For those wishing for more of a challenge to balance, close your eyes or stand on a soft surface such as a thick carpet or exercise mat.

PT Notes: Tree Pose is obviously a great posture to use for single leg balance training. It is also useful for improving strength and endurance of hip muscles and the foot and ankle muscles. It is somewhat quantifiable as you can rank the posture in difficulty from a modified version with the toe on the floor to an advanced variation with arms reaching overhead or even with the eyes closed. You can also time how many seconds the patient can balance in a given variation then progress to the next variation once they’ve achieved 30-60 seconds of stability.

I have heard of a therapeutic version of Tree Pose in which the patient lies on the floor and presses the ‘standing’ leg into a wall. The opposite is in an abducted/externally rotated position but supported by props. I haven’t used this variation myself but I can see how it might be useful to work on neutral foot position, co-contraction of anti-gravity muscles in the lower extremity and teaching frontal plane motion without weight bearing. This might be useful for patients who are very weak, confined to bedrest or who many have weight bearing limitations after surgery.

Top photo: Me, inspired by the trees in Yosemite
Modified Tree photo from Mobile Yoga Workout

It Hurts to be Sad & Angry

A recent study from the Netherlands shows that women are more sensitive to pain when they are feeling sad or angry. This study should come as no surprise to yogis, therapists (of all kinds) or anyone who works with those in pain. But I appreciate those out there doing good research to ‘prove’ that the mind is a powerful force that manifests in the body.

Of course negative emotions can affect your threshold for physical pain! Haven’t yogis, therapists and other mind-body advocates been aware of this for decades, perhaps centuries? But having evidence such as this is helpful for many reasons. Insurance providers may be more willing to provide ‘alternative’ therapies if there is solid proof that it may be more cost-effective than simply medicating patients or doing nothing. Studies such as these are also useful as references when educating a patient as to why addressing the mind is a valuable and sometimes essential element to their rehabilitation. As most Physical Therapists know, patients can sometimes become defensive if they perceive a suggestion that their pain is ‘in their head’. Other patients simply don’t believe that mind-body techniques are an effective use of their time. Studies like this can help many patients to try a new strategy they may have been resistant to or just unaware of.

The article mentions Cognitive Behavioral Therapy as a strategy to combat negative emotions. I would expect that there are many meditation techniques that may also be effective, at least in relatively mild cases. (If you suspect serious anxiety, depression, emotional trauma, etc find a mental health professional as quickly as possible).

Recently I had the pleasure of attending a meditation workshop called “Mind Dragons” with Sally Kempton. She taught a meditation technique that I think might be effective in addressing this particular mind-body link. Here’s what I recall:
*Think of a time that you were very sad or angry about something.
*Use pen and paper to write a story about that time.
*Read the story and circle all the words that feel emotionally charged to you.
*Begin to meditate on those words.
*Try to become aware of physical sensations associated with those words.
*Feel the density of those emotions. Where do you feel it? Can you sense a color or shape?
*Visualize breaking up that emotional energy, scattering the particles into the space outside of your body until you no longer feel their weight.
*Then (here’s the interesting part) gather those particles back, compressing them once again inside your body.
*Repeat the release, sending the emotion away

You can repeat this visualization of gathering and releasing as many times as you like. The point of the exercise is to really learn how to feel the emotions, thus diffusing the their power. She explained that our emotions, like dragons, can be the fierce guardians of treasure. If we can learn to ‘ride the dragon’ or to feel our emotions without fear, we can have access to a treasure trove of whatever lays behind the emotion. That could be peace of mind, wisdom, better health or perhaps, a higher pain threshold.

This study, published in the October issue of Arthritis Care & Reseach, included only women with and without fibromyalgia. It would be interesting to repeat this study with other groups including men and children and those with other types of chronic pain conditions. We need more research like this to integrate traditional and holistic care.


By the way, I also want to recognize my readers out there in Australia, Japan, and Canada and everywhere else in the world. Thanks for reading!

Asana Analysis: Eagle Pose/Garudasana

Last week I focused on the upper body in Eagle Arms so now for the rest of the pose:

Muscles Stretched: Glutues maximus and medius, piriformis, quadratus femoris, obturator internus,

Muscles Strenthened: Gluteus medius and minimus, tensor fascia latae, adductor magnus, longus and brevis, gracilus, pectineus, quadriceps, soleus, anterior and posterior tibialis, peroneals, intrinsic foot muscles.

Points of Body Awareness:
*Begin by activating the feet: spread the toes and lift the arches. Imagine there is a robin’s egg under the arch. Try to keep the arch lifted just that much, no less or more. This is neutral foot posture.
*As you lift one leg, maintain the neutral foot posture in the standing leg.
*Bend slightly at the hip and knee of the standing leg in order to wrap the top leg around the standing leg.
*Squeeze the thighs together.
*When you wrap the arms together use the opposite alignment. If the left leg is on top of the right, place the right arm on top of the left.
*Are the hands or forearms bisecting your vision, separating the left eye from the right? This obscured gaze will make balance more challenging.
*How freely can you breath as you squeeze and compress everything into the center?
*Try to hold for 3 to 6 slow, steady breaths.

To Modify: If you can’t wrap your foot around the standing leg, that’s perfectly fine. Just squeeze the foot toward the the outer calf of the standing leg. Or press the the big toe onto the floor or on top of a block which will make it somewhat easier to balance.

To Challenge: Squat more deeply and bring the elbows toward the thighs. This further compresses the front body and restricts the breath, which is good for enhancing awareness of the back body and learning to breath into the ‘back’ of the lungs. It is also a deeper stretch for the hips and back muscles.

PT Notes:
The greatest benefit of this pose, from a therapeutic point of view, is the challenge to balance. Not only does it improve the strength and coordination of the leg and intrinsic foot muscles, it also obscures the vision. By reducing the visual input, one must learn to rely more on proprioception and the vestibular system. Eagle is a nice midway point between using the gaze for balance and removing it entirely by closing the eyes.

Patients with hip, knee and ankle injuries should use caution with this posture. The combination of hip flexion/adduction and internal rotation may be irritable to someone with an arthritic hip, an inflamed psoas, or a labral tear. And it certainly should be avoided in patients who’ve had a total hip replacement.

Wrapping the foot around the standing leg results in medial rotation of the tibia on the femur, which may be a desirable mobilization but may also be detrimental. This element of the posture is contraindicated for patients s/p ACL reconstruction for at least 6 months (in accordance with the surgeon’s direction), until the patient has demonstrated good tolerance for rotational stress as evidenced by achievement of terminal knee flexion, and ability to cut and pivot without pain or compensation.

These restrictions would also be relevant for patients with other knee surgeries including meniscal repairs, chondral surgeries and total knee replacements. For non-operative tears of the MCL and meniscus, let pain be your guide as to when or if the full expression of Eagle pose is appropriate. There are certainly benefits to be had without fully wrapping the leg, including strengthening of the standing leg and working on balance with obscured visual cues.

All standing balance postures are great rehabilitation for those who’ve had ankle injuries but again, wrapping the foot around the the standing leg should be avoided, at least temporarily, after an ankle injury. The pose tends to invert and plantarflex the ankle, potentially stressing or over-stretching the lateral ligaments.

Even those without injuries should use caution when wrapping the top leg around. If the hip is tight, one could easily compensate by over-mobilizing the the knee and/or ankle. Be sure to work up to the full pose methodically and mindfully.




Photo credits:
Garudasana pose from Asheville Yoga Center
Actual Eagle picture taken by my husband in Homer, AK

The Joy of Yoga

I absolutely love this photo! This kid is the embodiment of kapha in balance; strong, serene and sweet. His obvious joy is infectious. How can you look at him and not feel good?

The photo is from Niroga, which is a non-profit based in Oakland, CA. They work to provide yoga to underserved populations including at-risk youth, cancer survivors, and people with addictions. And apparently their program really works, according a post earlier this week from YJ’s Yoga Buzz.

To me, this is what yoga really is all about. It’s not about acquiring the perfect yoga butt. It’s not about running off to India or learning esoteric philosophy. It’s not about mastering the perfect headstand. It’s about giving people, all people, tools for self-empowerment and peace.

Check out their website for more information and inspiration. If you live in the Bay Area, you may be interested in their teacher training programs. If you live somewhere else, you just may be inspired to figure out how you can make a difference in your own community.

Niroga Institute



On a different note, I’ve noticed a recent spike in readers from the Netherlands. Whoever you are, thanks for reading. I admired the enthusiasm your country showed the past couple of years at both the Winter Olympics and the World Cup. And you’ve gotta love all that orange! Maybe someday I’ll make it to your country for a visit but until then it’s nice to have a virtual connection. Dank u wel!

Asana Analysis: Eagle Arms Pose/Garudasana

I am going to go over another ‘half’ of a posture today, the upper part of Guarudasana or Eagle Pose. Like Cow’s Face Arms this pose can be done with the arms only, seated or standing in any other position.

Muscles Stretched: Posterior deltoid, middle and lower trapezius, rhomboids, teres major, infraspinitus, teres minor, triceps (slightly), and latissimus dorsi (but not if lumbar lordosis is maintained). Also possibly the levator scapulae (more on that later).

Muscles Strengthened: Infraspinatus, teres minor, pectoralis major and minor, serratus anterior

Points of Body Awareness:
*Is there any pinching or sharp sensations in the shoulders, elbows or wrists? If so, try a modified version described below.
*Once the arms are in position, be sure to move the elbows forward (protraction), then slightly upward (flexion) to maximize the energy of the pose and to increase the stretch of the muscles attached to the shoulder blades.
*Breath into the space between the shoulder blades. Broaden the back with each inhalation and relax the shoulders away from the ears with each exhalation.

To Modify: If the hands don’t come together, you can hold onto a strap in both hands but continue to actively move the backs of the hands toward the midline.

For a more gentle stretch, try pulling one arm across the chest with the opposite hand but maintain external rotation of the arm being stretched by keeping the forearm vertical, with the fingers pointing up toward the ceiling.



PT Notes: Eagle arms pose is essentially an advanced variation of a posterior capsule stretch but the shoulder is externally rotated isometrically rather than passively internally rotated. This is not a pose that I would recommend for anyone with an acute or subacute rotator cuff injury however I think it is excellent for improving blood flow and maintaining strength in a healthy rotator cuff. This posture may be useful for those with adhesive capsulitis, with chronic anterior instability, and for anyone with trigger points in the rhomboids, teres major and trapezius muscles.

I have formulated the theory (I have absolutely no proof of this) that the Eagle Arm pose can actually stretch the levator scapulae muscle, specifically the insertion on the scapula. I came up with this after I held this pose for a while one day and could swear that I felt it mostly at the superior angle of my shoulder blade. When I released the pose, I palpated that spot and it felt slightly tender. At first, I didn’t think this made much sense but once I thought about it, I realized that protraction moves the insertion point further away and by raising the arms up, the scapulae begin to upwardly rotate, further stretching the levator scapulae (which is why it is felt more on the side of the top arm). I don’t think everyone can achieve this particular aspect of the stretch because I believe the shoulders need to approach or exceed 90 degrees of flexion in the pose. For those who are very tight in the shoulders just achieving adequate adduction with external rotation will be a challenge so they will be unlikely to feel the stretch in the levator scapulae.

So what is the therapeutic value of my theory? For swimmers, gymnasts and others who tend to be very flexible and generally need more stability over mobility, this may be a good way to address trigger points in the levator scapulae without requiring the joints to be stretched to end-range, in other words, no need to bury to the nose into the armpit, stretching and pulling all the facet capsules, etc along the side of the neck.

Photo Credit: Yoga art + science

Make the Most of Fall's Fare

Two weeks ago I wrote about the transition of seasonal foods at the farmers market in Saying Goodbye to Berries. This week, I want to share an excellent resource with those of you interested in making the most of seasonal eating. Russ Parson’s book, “How to Pick a Peach” is full of fascinating and useful information. In the introduction he states that eating seasonally and locally “may indeed be good for the planet but ... I’m mainly interested in fixing a good dinner.”

Books like this just might be critical for public health. The CDC recently reported that only 32% of Americans eat at least 2 servings of fruit per day (including juice!) and only 26% have at least 3 servings of vegetables per day. The report states that we need to improve access, availability and affordability of produce, which I’m sure is true to some degree. But as Parsons points out in his book, America has access to more fruits and vegetables now than ever, and we only spend 11% of our disposable income on food. That is less than any other industrial nation and less than half of what our grandparents spent. I believe that part of the reason we don’t eat enough fruits and vegetables must be that we often just don’t know how good they can taste, given the right timing, storage and preparation.

“How to Pick a Peach” is divided into four main areas, Spring, Summer, Fall and Winter. Each section is subdivided into several pages dedicated to a single fruit or vegetable or group of related produce. For example, Fall has sections on broccoli and cauliflower, mushrooms, peppers, winter squash, apples, pears/Asian pears and quinces, and persimmons and figs. Each of these seven sections begins with a narrative description of the fruit or vegetable’s agricultural history, unique characteristics, and interesting tidbits. Then Parsons lists the critical information: Where They’re Grown, How to Choose, How to Store, How to Prepare and One Simple Dish. He then finishes the section with at least a couple of recipes that highlight that particular produce.

As if recipes, history, and helpful hints for buying and storing Nature’s bounty were not enough, the book also has essays preceding each season that describe the business of farming in America. And the introduction to the book is a fascinating look at the history of farming and grocery shopping in America. Whether you want a great non-fiction book to read cover-to-cover or you just want a good reference to keep in your kitchen, this book has it all. Before I read this book, I had no idea what to do with a butternut squash but I look forward to making this particular recipe again soon:

Caramelized Winter Squash with Rosemary Gremolata
6 Servings
2 Tablespoons pine nuts
2 teaspoons of minced fresh rosemary
2 teaspoons of minced lemon zest
1.5 teaspoons minced garlic
2 Tablespoons fresh lemon juice
2 Pounds peeled winter squash, cut into roughly 1/2 inch cubes
Salt
Freshly ground pepper

Toast the pine nuts in a small skillet over medium heat, stirring, until they are lightly browned and fragrant, about 10 minutes. Set aside.

Combine the rosemary, lemon zest and garlic in a small bowl and add just enough lemon juice to moisten. Stir together roughly with a spoon, crushing and smearing them to make a thick paste. The pieces of garlic and rosemary should be extremely fine because they will need to cook in a flash. Set aside the herb paste and remaining lemon juice.

Heat a large nonstick skillet over medium-hight heat. Add the oil and when it is very hot, add the winter squash. Sprinkle with 1 teaspoon salt and toss so that the squash is evenly coated with oil and seasoned with salt.

Cover tightly and cook, without stirring, for 2 minutes. Remove the lid and toss to stir the squash. The cooked sides should be starting to caramelize. Cover again and cook for another 2 minutes.

Remove the lid and toss to stir. Reduce the heat to medium and continue cooking, stirring occasionally, until the squash is just tender enough to be pierced with a sharp knife, about 5 minutes. The cubes should appear somewhat glazed and browned on most of their surfaces, but they should not be so well cooked that they are falling apart.

Sprinkle the herb mixture and the remaining lemon juice over the squash. Toss to coat, letting the herb mixture sizzle briefly and become aromatic. Taste for salt and lemon juice. Season with pepper to taste. Scatter the toasted pine nuts over the top and transfer to serving bowl. Serve.

(I must confess that I accidentally crushed the pine nuts up with the herb paste. It was a tasty mistake, one I think I’ll repeat.)

Click the link below to buy this book now for only $5.98. You can't beat that!

Remembering Sandra

When I went into work early that morning, I placed a flyer about a photography workshop on Sandra’s desk, forgetting that it was the day she was to leave for her trip to Australia. She was so excited about that trip. She was looking forward to indulging in her passion of photography, especially architectural photography. It was a unique hobby. She was a unique woman. She dreamed of a second career as a photographer although she was an excellent, ambitious physical therapist.

I was reminded that she was flying that day after my colleagues and I watched the 2nd plane run into the World Trade Center. When we heard that a plane had crashed into the Pentagon, we tallied all the people we knew were flying that day... Sandra, a coworker’s father, a friend of a friend. We worried, we prayed, we waited for casualties to come in to our hospital, we waited to hear from our friends and loved ones. When we found out that the plane that crashed into the Pentagon had taken off from Dulles airport en route to LA, a coworker insisted that Sandra had flown out of Baltimore. We held our breath, we waited, we assured our own frantic loved ones that we were fine. Then we heard a guttural cry come from our manager’s office. Then we knew for sure. Sandra was on that flight. My colleague, my friend had just been killed by terrorists.

It was shocking. It was sickening. Why Sandra of all people?

Sandra Teague was my age. We were physical therapists working at Georgetown Hospital. We didn’t work directly together but we sat back to back in our office. Her reputation was one of an assertive, strong and hardworking PT. She treated inpatients at the hospital, helping them to regain their strength and function after surgeries or major illnesses. She wasn’t a close friend but we regularly went to the same parties and happy hours. She was at my 30th birthday party 8 months before she died.

In life, Sandra was someone I would have described as the odd girl out but pleasantly quirky. She was one of the only Republicans in our social circle. She liked George Bush, wasn’t afraid to say it but really didn’t care who shared her opinion. While the rest of us would go out dressed in the requisite little black skirt, she went out wearing jeans and an old leather jacket. She wasn’t afraid to let it be known who she had a crush on and when it wasn’t reciprocated, she moved on seemingly unscathed. In death I realized that she was someone who wasn’t afraid to be herself. In retrospect, her strength and her self-assuredness became examples of the life I want to lead.

Nine years after her death, I still wonder what she would think about all this craziness of the the post-9/11 world. I’m pretty sure that she would not approve of burning the Quaran but I also think that her opinions on many other issues would be different from my own. Whatever she would think, I know that she would have shared her opinion in an honest and respectful way. So in memory of Sandra, here’s another affirmation from Kripalu on the yama, Satya or Truth:

I live in truth. I speak the truth to myself and to others. When offering my truth in the form of feedback I am sensitive the the feelings of others; I speak in the spirit of love. I also take responsibility for my actions. I do not blame anyone for my experience; I honestly see my own part in every situation.

Tomorrow, on the 9th anniversary of 9/11, I hope that truth will be honored. I hope that we can all learn to be more honest with ourselves, yet respectful of others. And I hope that fewer people will react in fear and that more people will move toward peace.

New Year's Eve 2000:

My 30th Birthday Party:


We'll never forget you, Sandra!

Asana Analysis: Cow's Face/Gomukhasana Part 2

Last week I covered the top half of this pose in Cow's Face Arms. This week I’ll go over the rest of the pose, specifically what is happening in the hips.

Muscles Stretched: Gluteus maximus, medius and minimus, tensor fascia lata, piriformis, possibly other small rotators of the hip including obturators and gemelli.

Points of Body Awareness:
*Is your spine in a neutral position? Is there an inward curve in the small of your back? Is the pelvis tipping slightly forward? If not, use props to elevate the hips
*Actively bend the ankles (dorsiflex) while you hold the posture. This will help to protect the knees and provide a sense of stability within the pose.
*There should not be any discomfort in the knees. If so, modify or find an alternative pose.
*Are you able to feel grounded? Can you let go, especially on the side of the top leg? Can you let the sit-bone on that side descend and find symmetry in the side waists?
*Hold this posture for at least 6 breath cycles.

To Modify: If you are unable to achieve a neutral spine position or if the posture feels too intense, sit on a block, folded blankets or a bolster.

There is a supine version of the stretch where you lie on your back, cross the thighs, bring the knees toward the chest and grasp the legs just above the ankles. Keeping the knees together, spread the ankles apart until you feel a stretch in the outer hip area.

To Challenge: Fold forward over the legs to increase the stretch in the hips. This can be done with the arms still in Gomukhasana posture which will increase the stretch in the shoulders or the arms can be released and relaxed by your sides.

I like to do a version of Viloma Pranayama or Interrupted Breath in this posture. Inhale completely. As you begin to fold forward, exhale 1/3 of the breath. Pause for a few seconds. Then continue to fold forward while exhaling 2/3 of the breath. Pause. Then exhale completely as you fold all the way forward over the legs. Inhale completely as you rise back up.

PT Notes: In my experience, patients tend to really enjoy this pose (mostly young to middle-aged outpatients in a sports medicine clinic). I have often used Gomukhasana for patients with low back pain and hip problems including DJD and impingement. This posture is possibly safer for patients with HNP than more traditional supine piriformis stretches because it is easier to maintain a neutral lumbar lordosis, provided the appropriate modifications are used. It can also be less irritating to those with hip problems as it maintains external rotation during flexion/adduction, avoiding compression of the iliopsoas, the anterior labrum or joint surfaces.

This pose may not be appropriate for patients with knee injuries or s/p total hip replacement.

Asana Analysis: Cow's Face Arms/Gomukhasana

This post is only about half of a posture called cow’s face. I’ve decided to break it down like this because the full posture has a lot happening and while the bottom half of this pose is rather specific to yoga, the position of the arms is similar to a stretch done very often by physical therapy patients and those in the general fitness world.

Muscles Stretched: Top arm - triceps, teres major. Bottom arm- supraspinatus, infraspinatus, teres minor

Points of Body Awareness:
*Sit on the edge of a chair or on the ground with the spine in a neutral position - inward curve in the small of the back, slight outward curve between the shoulder blades, chin level to the ground, crown of the head rises up toward the ceiling.
*Start off by reaching one arm up in a motion that mimics wiping sweat off your brow with the inner, upper arm. This will create better alignment in the ball-and-socket joint by rolling the arm in (actually GH external rotation).
*Is your elbow pointing strait up toward the ceiling or is it pointing more out to the side?The elbow should be pointing strait up or slightly forward, never out to the side.
*Continue to actively roll the upper arm in towards the ear.
*Is the shoulder of the lower arm rolling forward? If so, draw the shoulder back by squeezing the shoulder blade down and back.
*The muscles between both shoulder blades are active to help open and lift the top of the chest.
*Where is the head in relation to the shoulders? If the the head is forward, draw it back so that the ears are in alignment with the center of the shoulders.
*Are you leaning or twisting toward one side? The waist and ribs should be evenly spaced on both sides and the collarbones parallel to a wall in front of you.
*Lift the breastbone and lengthen the collar bones as you inhale and exhale.

To Modify: Use a strap to extend your reach as pictured below:



If you want to just focus on the bottom arm, use a strap across the opposite shoulder and pull strait down with opposite arm. You can even loop the strap so that you can rest the wrist in the loop rather than gripping the strap. This will allow for less tension throughout the arm, neck and shoulder.

PT Notes: This is a much better stretch than the typical overhead triceps stretch often done as a part of fitness classes, in which you simply pull one elbow behind the head. By doing ‘Cow’s Face’ stretch, you optimize the position of the glenohumeral joint and ensure that the humeral head is externally rotated, clearing the greater tuberosity away from the acromium process. Gomukhasana also doubles the efficiency of the stretch by working on both arms simultaneously. And you do all this while improving postural awareness and practicing active relaxation.

If your patient wants to increase the sensation of the stretch in the triceps, have them try to ‘lengthen’ the humerus by reaching up more through the elbow but at the same time, anchoring the scapula. (This works, I know this through personal experience. I happen to be freakishly flexible in the shoulders and with the standard, behind-the-head stretch I can pull my elbow across to the opposite ear. This amount of shoulder adduction is completely unnecessary and not at all functional. It is possible for a flexible person to achieve a good stretch without placing the joint in an unstable or extreme position.)

I like the single side modification described above when working on improving a patients’ behind-the-back ROM. By using the opposite shoulder as a pulley, it is much easier to focus on scapular alignment and posture. It is also a more relaxed posture which allows for more concentration to distinguish discomfort from red-zone pain.

For more details on this posture, see Yoga Jounal.

Photo credit: Yoga Journal