People with glaucoma, moderate-to-severe myopia, a history of positional vertigo, cervical spine disease, or uncontrolled high blood pressure should generally avoid Downward Dog (Adho Mukha Svanasana). The pose places the head below the heart and loads the wrists and shoulders with a large percentage of body weight, creating a specific set of physiological stresses that are harmless for most people but risky for others. The list of who should sit this one out is longer and more evidence-backed than many yoga practitioners realize.
Glaucoma and Eye Pressure
This is the most well-documented medical concern with Downward Dog specifically. A study that measured intraocular pressure (IOP) during four common yoga poses found that Downward Dog produced the highest spike of all positions tested. In both glaucoma patients and people with healthy eyes, IOP jumped from a baseline of about 17 mmHg to roughly 28–29 mmHg the moment participants assumed the pose. Every single eye in the study showed an increase.1PLOS ONE. Intraocular Pressure Rise in Subjects with and without Glaucoma during Four Common Yoga Positions That is a jump of more than 60 percent, and it happens almost immediately upon entering the position.
A systematic review and meta-analysis looking at yoga’s effects on IOP in glaucoma patients confirmed the pattern: inversion postures cause a rapid rise in eye pressure soon after starting, while certain breathing techniques and gazing exercises actually reduce it.2PubMed Central. Effect of yoga on intra-ocular pressure in patients with glaucoma: A systematic review and meta-analysis The distinction matters. Yoga as a whole is not off-limits for people with glaucoma. Specific poses where the head drops below the heart are the problem, and Downward Dog is the most common one people encounter in a typical class.
If you have glaucoma or are considered a “glaucoma suspect” (borderline elevated IOP, family history, thin corneas), the safest move is to skip Downward Dog entirely and substitute a non-inverted alternative. The pressure spike is transient and reverses when you stand back up, but repeated daily spikes over months or years could accelerate optic nerve damage in someone already at risk. This is an area where even brief, reversible increases matter because the damage they contribute to is cumulative and irreversible.
Myopia and Retinal Risks
Moderate-to-severe nearsightedness creates a separate category of eye risk in head-down poses. A published case report described a 32-year-old woman with moderate myopia who developed sudden floaters and blurred vision in one eye after a head-down yoga posture. Examination revealed posterior vitreous detachment and a small hemorrhage near the optic disc.3PubMed Central. Posterior Vitreous Detachment Precipitated by Yoga
The mechanism here is different from the glaucoma concern. Myopic eyes are elongated, which stretches the retina thinner and makes the vitreous gel inside the eye more prone to pulling away from the retinal surface. Rapid shifts between upright and head-down positions can generate enough force to trigger that separation. Posterior vitreous detachment by itself often resolves without lasting harm, but it can sometimes progress to a retinal tear or detachment, which is an emergency. If you have moderate or high myopia (roughly −3.00 diopters or worse), discussing inversions with your ophthalmologist before incorporating them into a regular practice is a reasonable precaution. The case report’s authors specifically recommended that myopic patients be warned about the possible ocular complications of head-down yoga postures.3PubMed Central. Posterior Vitreous Detachment Precipitated by Yoga
Positional Vertigo
Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo triggered by head movements. Tiny calcium carbonate crystals in the inner ear become dislodged and drift into the semicircular canals, sending false motion signals to the brain whenever the head tilts into certain positions. The result is sudden, intense dizziness that can last seconds to minutes.
A study comparing yoga practitioners to non-practitioners found a striking difference. BPPV was diagnosed in about 15 percent of yoga practitioners compared to under 2 percent of controls, a statistically significant gap. The posterior semicircular canal was involved in seven of the eight affected yoga practitioners. There was no correlation between how many years a person had practiced yoga and whether they developed BPPV, but there was a positive correlation between weekly practice hours and BPPV occurrence.4DergiPark (The Turkish Journal of Ear Nose and Throat). Can yoga cause benign paroxysmal positional vertigo?
Downward Dog is a prime candidate for aggravating this condition. It places the head in a forward-and-down position, then transitions back to standing, which is exactly the kind of positional change that dislodges or redistributes those inner ear crystals. If you already have a BPPV diagnosis, or if you experience brief spinning sensations when you tilt your head or roll over in bed, Downward Dog is one of the poses most likely to set off an episode. Even people without a formal diagnosis who notice occasional positional dizziness during yoga should take it seriously, because an unrecognized BPPV episode mid-pose could lead to a fall.
Cervical Spine Problems and Arterial Dissection
Downward Dog places the neck in a somewhat compressed, flexed position while the arms bear weight. For most healthy spines, this is not a problem. But if you have cervical disc herniations, cervical spinal stenosis, or significant degenerative changes in the neck, the position can compress nerves or reduce blood flow through already-narrowed spaces.
A more dramatic risk, though thankfully rare, is cervical arterial dissection. A case report documented a 63-year-old man who suffered concurrent cervical myelopathy from multilevel spondylopathy, right vertebral artery dissection, and left cervical carotid artery dissection following a yoga session.5PubMed Central. Cervical arterial dissection and traumatic myelopathy following yoga: surgical case report Arterial dissection is a tear in the wall of an artery, and in the neck it can cause stroke. This patient had pre-existing multilevel spondylopathy, meaning his cervical spine was already compromised before yoga pushed it past its limits.
The people at highest risk for this kind of catastrophic event are older adults with known cervical degenerative disease, anyone with connective tissue disorders that weaken blood vessel walls, and people with a history of neck surgery or prior dissection. If you fall into any of these categories, poses that load the neck under partial inversion deserve careful discussion with your doctor before you attempt them. Younger, healthy practitioners are at very low absolute risk of dissection, but the consequence is severe enough that knowing the warning signs (sudden severe headache, neck pain, vision changes, or weakness on one side of the body during or after yoga) is worthwhile.
Uncontrolled High Blood Pressure
When you flip your torso below your heart in Downward Dog, gravity shifts a column of blood toward your head and upper body. In someone with well-controlled blood pressure, the body adjusts. In someone with uncontrolled hypertension, this creates a sudden surge of pressure in the vessels of the head, eyes, and brain. The concern overlaps with the glaucoma issue but extends to the risk of headache, nosebleed, and in extreme cases, hemorrhagic stroke. People with blood pressure that is consistently above 160/100, or anyone who is symptomatic from their hypertension (headaches, visual disturbances, shortness of breath), should avoid inversions until their pressure is brought under better control with medication and lifestyle changes.
The same caution applies to anyone on blood-thinning medications, since the head-down position can increase the risk of bleeding in the brain or eyes if a vessel wall gives way under higher-than-normal pressure. This is largely a common-sense guideline rather than one backed by randomized trial data, but it is endorsed by most cardiology and yoga therapy organizations.
Wrist and Shoulder Injuries
Downward Dog asks the wrists to bear a substantial portion of your body weight in full extension, a position that is already near the end of most people’s comfortable range. If you have carpal tunnel syndrome, a recent wrist fracture, a ganglion cyst, or chronic wrist tendinitis, the pose is likely to aggravate the problem. The load is not trivial: your hands are carrying roughly 35 to 45 percent of your total weight depending on your proportions and how the pose is set up.
Shoulder injuries are similarly problematic. The pose requires the arms to reach overhead while bearing load, which brings the shoulder into a range where impingement can occur if the rotator cuff is inflamed or torn. People recovering from shoulder surgery, labral tears, or frozen shoulder will often feel a sharp pinch or deep ache in Downward Dog that signals the joint is being pushed into an unsafe zone. Forcing through that sensation risks further tearing or re-injury.
What About Pregnancy?
Common advice in yoga studios is to avoid inversions during pregnancy, and Downward Dog often gets grouped into that warning. The evidence, however, is more nuanced than the blanket prohibition suggests. A study examining maternal and fetal responses to 26 yoga postures in women between 35 and 37 weeks of pregnancy found that vital signs, oxygen levels, and uterine activity remained normal across every single pose tested. Fetal heart rate was also normal throughout. There were no falls, injuries, or reports of decreased fetal movement, contractions, fluid leakage, or bleeding in the 24 hours following the sessions.6Obstetrics & Gynecology. Yoga in Pregnancy: An Examination of Maternal and Fetal Responses to 26 Yoga Postures
That said, the study involved healthy women with uncomplicated, singleton pregnancies and was conducted under supervised conditions. Women with placenta previa, preeclampsia, a short cervix, or other high-risk conditions were not included and should follow their provider’s guidance. And even healthy pregnant women in the third trimester often find that the growing belly makes Downward Dog physically uncomfortable or that the head-down position causes reflux or lightheadedness. A modified version with hands on a wall or elevated surface can capture the shoulder and hamstring stretch without the full inversion.
The broader takeaway is that blanket bans on yoga during pregnancy are not well-supported by the evidence in healthy, low-risk pregnancies. But Downward Dog specifically may become impractical or uncomfortable as pregnancy progresses for simple mechanical reasons, quite apart from any safety concern.
Tight Hamstrings and Lower Back Pain
Downward Dog is often taught as a hamstring stretch, but if your hamstrings are very tight, the pose can actually hurt your lower back. When the hamstrings cannot lengthen enough to allow the pelvis to tilt forward, the slack has to come from somewhere, and that somewhere is usually the lumbar spine. Instead of maintaining its natural curve, the lower back rounds into flexion, which loads the discs and ligaments in a way that can cause or worsen pain. Anyone with an active disc herniation, sciatica, or acute lower back strain should either modify the pose (bent knees, hands elevated) or skip it until the acute phase resolves.
The connection between hamstring tightness and reduced lumbar mobility is well established. People who sit for long hours, whether at a desk, in a car, or in a dental operatory, tend to have shorter, stiffer hamstrings, which in turn limits how much their lumbar spine can move and increases stress on the lower back. For this population, jumping straight into a deep Downward Dog without bending the knees is counterproductive. The goal of the pose is a long, neutral spine, not straight legs at any cost. Bending the knees even a lot is almost always the right call for someone who cannot touch their toes while standing.
When Dizziness Happens in Class
Even people with no diagnosed conditions sometimes experience lightheadedness or a head-rush sensation during Downward Dog, particularly first thing in the morning, after eating, or when dehydrated. This is usually orthostatic in nature: blood pools in the head during the pose, and when you transition to standing, blood pressure momentarily drops. The sensation typically passes within seconds and is not dangerous, but it becomes a safety issue if you are on a hard floor, surrounded by other practitioners, or near furniture. A fall from standing height, even a controlled collapse onto a yoga mat, can cause injuries far worse than anything Downward Dog itself would have caused.
If you consistently feel dizzy coming out of Downward Dog, slow the transition. Drop to your knees first, pause in a tabletop position for a breath or two, then come up to standing gradually. If dizziness persists despite this adjustment, you may have an underlying issue worth investigating: low blood pressure, dehydration, anemia, or the positional vertigo discussed earlier are all common culprits.
Practical Modifications Worth Knowing
For most of the conditions listed above, the issue is not that the person should never do anything resembling Downward Dog. It is that the full, traditional version of the pose creates specific stresses that could be avoided with simple changes.
- Wall Dog: Place your hands on a wall at hip height and walk back until your torso is roughly parallel to the floor. This gives you the shoulder and hamstring stretch without putting your head below your heart, eliminating the IOP spike, the blood pressure surge, and the vertigo trigger.
- Puppy Pose: Start on hands and knees and walk your hands forward while keeping your hips above your knees. This gets a similar shoulder and upper back stretch with far less wrist loading and only a mild change in head position.
- Bent-knee version: In a standard Downward Dog, bend the knees generously. This takes the hamstring demand out of the equation and allows the lower back to maintain a neutral curve. Useful for anyone with tight hamstrings or lumbar disc issues.
- Forearm Dog (Dolphin Pose): Drop onto your forearms instead of your hands. This eliminates wrist extension entirely and is a good substitute for anyone with carpal tunnel or wrist injuries, though it still inverts the head.
The choice of modification depends on which specific risk applies. Someone with glaucoma needs the Wall Dog because the head position is the problem. Someone with carpal tunnel might be fine with Dolphin Pose. Someone with both would need the wall version. There is no single “safe” modification that covers every contraindication, which is why understanding the specific reason for the restriction matters more than memorizing a one-size-fits-all substitute.
What Yoga Teachers Often Get Wrong
The most common mistake in group yoga classes is treating Downward Dog as a resting pose that everyone should be able to hold comfortably. In many flow-style classes, it serves as the default transition and recovery position, appearing dozens of times in a single session. For someone with any of the conditions above, that frequency is the problem as much as the pose itself. Holding Downward Dog once for five breaths is a very different physiological event than cycling through it 30 or 40 times in an hour.
Teachers also tend to underestimate how many students have undiagnosed conditions that make inversions risky. Not everyone with glaucoma knows they have it; the disease is famously asymptomatic until significant damage has occurred. Not everyone with mild BPPV has been to an ENT. And not everyone with early cervical degeneration has had imaging. A good intake process asks about eye disease, dizziness, neck problems, and blood pressure, but many studios skip this or rely on a generic liability waiver. If you know you have any of the conditions discussed here, the responsibility falls on you to speak up before class starts or to modify the pose on your own. Waiting for a teacher to notice and intervene is not a reliable safety strategy.